A House Divided
Cardwell C. Nuckols, Ph.D., Tom M. Saunders, Ph.D., and Marybeth Weigand, M.A.
Using the same multiple families group (MFG) approach found to be successful with family systems and corporations, a hospital administrator and two family systems consultants are providing creative innovations with the difficult "dual diagnosis" in a unique hospital environment. Staff, lovingly called 'persons not paying for treatment,' and patients as 'persons paying for treatment,' come together on a regular basis to form a symbolic experiential family where there are no secrets. By addressing such common denominators as isolation, loss, and healthy expression of anger and sexuality, this hospital setting becomes the ultimate environment from which to emerge a healthy and whole person. In so doing, the common 'splitting' of hospital personnel, which frequently happens with the dual diagnoses, can often be avoided.
In the discussion of the treatment of the dual disorder patient, recent articles have focused on treatment technology, such as the use of medication and psychotherapy. However, the single greatest difficulty in managing a productive dual disorder unit involves staff who provide care rather than just the treatment technology itself.
For example, how do you place a psychiatrist, an MSW, a recovering alcoholic and addict, and a registered nurse, on a treatment unit and say to them, "Be a healthy family and work together." Obviously, all of these professionals come from various experiences and different training. If some cohesion cannot take place, the unit then exists in some array of dysfunction. It is only when these professionals can come together and simulate some semblance of a healthy family that the greatest gift becomes evident. This greatest gift is the ability on the part of the treatment team to replicate a healthy family, thus giving to the persons paying for treatment an opportunity to trust and take appropriate risks ¾ often for the first time in their lives.
One hospital setting * has found that using a modified multiple families group (MFG) model, already proven to be successful with family systems and corporations, most closely replicates an ideal healthy surrogate family, and provides the optimum nurturing environment in which positive change is most likely to take place. A daring hospital administrator and two outside family systems consultants are providing creative innovations with the difficult "dual diagnosis" in a unique hospital environment.
History of MFG in Dual Diagnosis Treatment
Peter Laqueur is credited with the first documented use of MFG in the sixties. With his schizophrenic in-patient population and their families, he learned first hand about the benefits of utilizing group process to gain insight into experiential family process.
Saunders (1990) expanded Lacquer's model in the seventies at a residential treatment center for adolescent schizophrenics, with some dual disorders. Three and four generation families met weekly and "extended family network" included significant
others as well such as twelve step sponsors, extra marital affairs, and all ex's. Dual disorders were eventually eliminated from the treatment program because of several experiences involving negative leadership characteristics.
Bowen (1976), Papp (1976), and others have also utilized the MFG format with good results in community mental health settings as well as hospital based groups.
Kearney (1984) did a comparative study of MFG and Individual Conjoint Family Therapy (ICFT) with an outpatient chemical dependency population with results indicating no differences between the two modalities in the pre and post test measures. Monitored were changes in relationships, emotional and family adaptability, and cohesion and spirituality. Given constraints of staff availability, time, and budget, the author noted that MFG would likely yield superior results and be well justified as a methodology of choice.
Norgard (1989) did a comparative study with addicted adolescents and their families, again comparing results between MFG and Conjoint Family Therapy (CFT). This study yielded no significant differences in the measures of change taken. Noted were education of the family regarding the detoxification program, examination of family relationships for aftercare, development of family community to reduce the stigma of treatment, and enlisting family cooperation in the recovery process. Norgard also included a hypothesis regarding the benefit of building a bridge back to reality with the MFG modality.
While MFG is becoming a more familiar methodology of choice in many substance abuse treatment programs, and has been utilized with in-patient populations for many years, specific documentation of its use with the dual diagnoses is still sparse.
Research suggests that over 70% of hospitalized alcoholics have experienced at least one other episode of another substance abuse or psychiatric diagnosis in their past. Although detoxification in a structured hospital environment is well documented as the first step in treating this dual diagnosis, the accompanying behavior patterns and affective imbalance are rarely, if ever, diagnostically clear (Daley, Moss, and Campbell, 1987).
Substance abuse, seen through the MFG and systems modality, is viewed as serving a homeostatic and system-maintaining function (Goldenberg and Goldenberg, 1985). MFG, with all of the key players present, is the safest environment in which to return from the initial isolation of hospitalization. Life without the anesthesia of alcohol or other drugs to mask emotional pain is best seen through the eyes of other experienced families who have been down that road earlier. Accordingly, some modification of existing hospital programs is in order since isolation of the identified patient serves to exacerbate emotional pain rather than to ease it.
Minuchin (1989) speaks of the larger institutional system supporting hospitalization as related to the family system. Depersonalization begins at the instant a label has been applied by the system empowered with that authority. The act of labeling further serves to remove the scapegoat in question from personal responsibility and accountability. The individual paying for treatment is reduced to an entity removed and isolated from culture, family context, and rich personal history. By comparison, the intervention of the MFG model in the treatment plan serves to ameliorate the damaging effects of this process.
Hard To Love
Certainly, persons with dual disorders are, at times, most difficult to love. However, these individuals deserve and need the gift of a fair, consistent, and available environment. For example, the incest survivor with an eating disorder and alcohol/drug addiction with a co-existing borderline personality disorder has the amazing capacity to split staff. In splitting the hospital personnel, persons with dual disorders have unconsciously, or sometimes knowingly, recreated their own worst nightmare. This capacity is so well developed that if staff does not function as an effective mother and father team, then hospital personnel ends up taking their hostilities out on each other. Much like in the cartoons, one character incites a riot by throwing a stone in between two others ¾ who, unaware, then begin to battle with each other. This creates just another dysfunctional environment for the persons receiving treatment.
Toward A Consistent Environment
Many approaches have been tried with limited degrees of success regarding the establishment of a consistent recovery environment. Based on the assumption that the alcohol and drug disorder, as well as the other psychiatric diagnoses, are an integral part of the identified person's life, then a system that can integrate treatment philosophy, experience, and approach may meet the challenge with the difficult dual disorders.
When psychiatric and substance abuse units are separated geographically, integration of staff becomes even more difficult. One strategy which moves toward such integration has been to utilize a cross-training approach, such as MFG (Saunders, 1990), that allows different disciplines to come together with regard to the treatment of dual disorders. This cross-training approach only works when there is a forum provided to share varying points of view. It is critical that the physicians, nurses, social workers, and other helping professionals are able to reach some common ground with regard to philosophy and approach to care. Staff grand rounds allow all disciplines represented to discuss treatment philosophy and to begin to understand that although their terminology sounds drastically different, the underlying philosophies are often unified.
Finally, the cross-training approach works best when there are on-going stuffing's and communication among staff members. One of the most difficult problems is to reduce the level of scapegoating from one unit to another. This is best done when people understand that the goals for treatment are the same ¾ improvement with regard to the psychopathology and hopefully abstinence from alcohol and other drugs.
When the treatment units are in close proximity, developing similar unity among the staff 'family' is even more critical. For example, a unit may have an MSW and Ph.D. in one wing, while two recovering alcoholics share another office in another wing. This type of strategy usually leads to the RN's standing behind a nurses' station in utter confusion. The patients typically watch from nearby with knowing smiles on their faces. This is just like home!
A second process that is currently being implemented by the authors utilizes two outside family systems consultants to assist staff in this important integration. A unit manager cannot serve as a facilitator for their own staff. But staff will function better when a forum is created that allows them to air differences and discuss similarities. For example, the two visiting family systems consultants whose style much resembles Whitaker's symbolic experiential model (Whitaker, 1982), conduct intensive weekend family sessions. On Monday morning, these same consultants transition from the weekend into the Monday through Friday work week by facilitating an open unit staffing. This staffing gathers all available persons paying for treatment, hospital personnel from all units, and the outside consultants. This model, an open and honest 'no family secrets' meeting, takes place and beautifully transitions the work of the weekend into the work of the week.
All units begin to be perceived as one big family ¾ not necessarily happy ¾ by both staff and those persons paying for treatment. Obviously, staff take on a parental role, and the persons paying for treatment, that of siblings. As may be apparent by now, the term "patients" is rarely used on the unit, as that description often provides a stigma barrier of its own. Besides, most 'patients,' by the time they are admitted, have become more professional with people management than the 'staff' who are persons not paying for treatment. For this 'executive class' paying for treatment, who often complain about the quality of treatment being provided, (much worse than their last treatment center, of course) the recommendation is often made that they buy the hospital and fire the staff, or else start a quality program of their own. After all, they are the pros!
Each Friday afternoon, the persons who do not pay for treatment, i.e., the staff or parental role models, have their own group. This group is also facilitated by the outside consultants and allows the staff to work on their own personal and parental issues which relate directly to the care of families on the various units. This meeting allows a forum for the multidisciplined staff to deal with their differences and minimizes the amount of enmeshment or disengagement that typically takes place on a dual disorder unit.
While not perfect, this particular model, nicknamed 'the coliseum,' allows those paying, and those still learning, to participate in an environment that is fair, and most importantly, consistent. There also is the availability of other forums, such as the 'alumni' group which is totally facilitated by graduate experienced families in aftercare, for all persons to express feelings, grow personally, and most importantly, learn to trust each other in the process.
The 'Coliseum' Model
The 'coliseum' model of working with three and four generation families is designed to most closely approximate reality, and to above all, offer a low cost, efficient model that can easily be replicated to work with large numbers. As one participant put it, "It's like real life. You own your own chair, and what you do with it is always up to you." When the rules are explained during the initial moments, individuals are told to position themselves, in proximity to the group and their family, in the most responsible posture possible.
Just as in real life, the action is focused in the center; those who watch, from a distance, leave angrier than when they arrived. As participants move into the center ring to work, they must be accompanied by all family members. Those professionals attending will be seated in the outer ring unless they, themselves, choose to become a part of the action by moving to the center.
The plan is simple. Rather than focus on problems, symptoms, and the scapegoats unconsciously elected to present the family pathology, this model demonstrates how effectively Experienced families can help Present families. Experienced families are those who have already weathered difficult transitions and have learned the lessons which experience provided. Present families are those who are currently in transition. In addition, High Risk families, which can be easily predicted, can possibly be saved from experiencing every facet of each lesson for themselves.
By combining these families to work with each other, the model closely approximates what worked before therapy was ever available ¾ families helping other families. As the model does not remove an identified 'patient' (whom we would prefer to call the scapegoat), there is no integration necessary back into the mainstream.
'Extended family,' for the purpose of this model, includes everyone related, by marriage or by blood, within a 25 mile radius of the primary residence. Any non-related significant others should also be included; i.e., a neighbor acting as a surrogate parent, pseudo 'aunts' and 'uncles,' or any active romantic affairs ¾ and their families! The message behind the model is a simple one: Support is always available somewhere. Ask for support where you can find it instead of complaining about why it isn't available now or hasn't been in the past!
When professionals want to experience the full impact of the model, they are encouraged to bring their own extended families and become active participants in the group along side of persons whom they normally designate as 'patients' or 'clients.'
'No Secrets' Approach?
Secrets are the poison that eventually lead to the collapse of most family systems. The more underground and covert the secrets remain, the more devastation they create. When secrets are unspoken, they are read and acted out even more clearly by the next generation.
Sixth sense has long been recognized as an acceptable means of communication among animals. However, the most valuable information passed among the family unconscious often goes unrecognized and unheeded. Although Jung (1928) is reported to have written about the collective unconscious, academics still largely ignore this phenomenon as the most direct and intense communication. Psychic is still a word largely discounted by professionals, and even then, described as a gift given only to a select few. Taub-Bynum (1984), in a well documented book called The Family Unconscious, frankly discusses this phenomenon and describes the family energy field as "...a matrix of implicit energy vortices" through which members signal other members without conscious filtering."
When out of an extended family system of eleven members who had been estranged emotionally and geographically, four developed cancer in 1979, and did not report the same to each other for more than a decade, doctors dimissed the 'coincidence' as "...a disease which runs in the family." In another family, where suicide attempts of the thirteen year old daughter with sleeping pills were the cause for a family meeting, no one initially could recall any history of suicide attempts on either side of the family tree. However, a few weeks later, in a multiple families group, when the discussion turned to the suicide of another woman's husband, the father of the thirteen year old broke into sobs and produced a worn letter which his mother had written seventeen years earlier ¾ on the day she committed suicide with sleeping pills ¾ one week after he had married his present wife. To make matters more complicated, he was called out of state ten years after his mother's death by his sister's psychiatrist when his sister's attempted suicide failed ¾ with sleeping pills! Meaning well, but failing to listen to his own implied message, the psychiatrist reassured him, " You have saved your sister's life by coming here to be with her." No one in the the entire family had ever been told any of this history, and, in fact, the mother's death certificate indicated death by natural causes so that only her son knew the real story.
Hospital personnel, as a natural result of professional training and ethics, are prepared to listen to any 'secrets' which any individual member of a family who is hospitalized will share. As if that risk is not high enough, most hospital staff are continuously receiving calls from other well meaning family members who want to confide, "...for the hospitalized person's best interest" about another biased sample ¾ which, of course, the staff usually does not share with the person in the hospital. By having virtually no communication of importance outside of the entire system, the person hospitalized now begins to split the hospital staff into the same exact formations as the dysfunctional family from which they came.
Hospital As Home ¾ Staff As Family
Begin to imagine hospital as home and staff as family. Where hospitals are divided into units, the physical layout of the hospital begins to shape the dimensions of the treatment program as well. One might guess that architects unwittingly have as much to do with formal treatment as a janitor governs the flow within group process by where the chairs are placed!
The authors and staff have addressed these critical issues and developed a unique treatment program around the obstacles. Staff from various units are beginning to cross 'boundary' lines within the hospital walls and work conjointly with other programs than those for which they were originally hired. Much like Ford's Model T, the staff, as well as persons paying for treatment, begin to discover that most human beings are interchangeable parts; only the details have been changed to protect the innocent.
Furthermore, by combining all unit's staff and all persons paying for treatment together on at least a weekly basis, the geriatrics begin to interact with the schizophrenics because neither knows of the others' diagnoses. Addicts are taking their sing-a-long festivities over to the immobilized. And best of all, staff are beginning to resolve their own issues and share their feelings in front of everyone ¾ the ideal family systems model which rarely occurs elsewhere.
Moving Toward Fewer Walls
If, in fact, those in the helping professions wish to first help themselves through their own life work, what better opportunity to utilize a model, like this, that really works?
The line between "us and them" is excruciatingly thin and a matter of degree ¾ perhaps even an illusion. In this hospital setting, the decision was not to re-invent the wheel. Utilizing the MFG model as a cross-training approach, professional barriers are lowered and isolation among and within treatment teams and treatment units is reduced. The unilateral, cleansing effect of the 'no secrets' approach serves to assist in staff development regarding their own family issues thereby insuring a united team front which resists the splitting phenomenon among staff so often seen in any treatment system under stress. Issues such as personal scapegoating and the abscess created by family secrets which sabotage treatment effectiveness are reduced as commonality across family issues is valued and enhanced. As with the best of family systems, individual differences are respected, differing opinions are tolerated, and healthy individuation evolves without isolation or enslavement. In effect, the treatment team becomes the best possible with unique strengths and a common goal.
By combining a 'garden variety' of dual diagnoses along with staff from all units of a psychiatric hospital, the authors have moved toward a 'no secrets' approach in which the important elements of trust, cooperation, and support begin to emulate an ideal healthy family in which positive changes can be made within minimal time. This model also encourages person paying for treatment to develop a network among themselves and the aftercare community as opposed to becoming co-dependent upon the professional community.
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collective unconscious,; collected works. (ed. R.F. Hull). Princeton, NJ: University Press, 1928.
Kearney, Michael S. A comparative study of multiple family group therapy and individual conjoint family therapy within an outpatient community chemical dependency. Unpublished doctoral dissertation, The University of Minnesota, 1984.
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Norgard, Katherine L. Multiple family group therapy in a treatment center for adolescents. Unpublished doctoral dissertation, The Union for Experimenting Colleges and Universities, 1989.
Papp, Peggy. (1976). Brief therapy with couples and groups. P. Guerin (Ed.) Family therapy: theory and practice. New York: Gardner Press.
Saunders, Tom. Go ahead, kill yourself! Save your family the trouble: paradoxical therapy with familes. Plantation, Florida: Distinctive Publishing, Inc. 1990.
Taub-Bynum, E. Bruce. The family unconscious. Wheaton, Illinois: Theosophical Press, 1984.
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This article was published in the NAADAC Journal, March/April, 1992, under the title of “Healthy Families”
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