bClinical Psychologist, Family Services Center, San Francisco CA. .... of needs and problems to work on during therapy: (a) lack of trust, (b) difficulties .... parents for biological survival as well as psychological and existential identity (19).
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Fam Proc 29:59-71, 1990
Contextual Therapy: Brief Treatment of an Addict and Spouse GUILLERMO BERNAL, Ph.D.a CARMENZA RODRIGUEZ, Ph.D.b GUY DIAMOND, M.A.c aAssociate Professor, Department of Psychology, University of Puerto Rico, P.O. Box 23174, UPR Station, Rio Piedras, Puerto Rico
00931-3174; and Director of the University Center of Psychological Services and Research, University of Puerto Rico. bClinical Psychologist, Family Services Center, San Francisco CA. cDoctoral Candidate in Clinical Psychology, California School of Professional Psychology, Berkeley CA.
The clinical and theoretical applications of contextual therapy for the treatment of drug abuse are presented. A case study illustrates intervention strategies, the therapy process, and a contextual-intergenerational view of drug addiction. Contextual concepts of intergenerational processes, loyalty, fairness, accountability, and trust are defined and applied. Four stages of brief contextual therapy are presented, and the process is examined using examples from transcribed transactions of the therapy sessions. It is suggested that contextual therapy offers conceptual and methodological tools for working with complex situations often involved in drug abuse cases. A great deal of attention has been given to the family system as the base upon which drug abuse develops and is perpetuated (15, 17, 23, 25, 27). Several reviews of the literature (30, 33) suggest that drug abusers have much higher rates of contact with their family of origin than do comparable non-users in the United States. Increasingly, a link between nuclear family dynamics and drug abuse problems is being documented in the literature (22, 32, 33). Specifically, drug addiction has been shown to be associated with profound loss, incomplete mourning, and unsuccessful separation in the family of an addict (16, 17, 29). While a number of authors (17, 26, 30) have written extensively about intergenerational family conflicts and the multigenerational legacy of chemical dependency, few have developed treatments based on intergenerational family processes (4, 28). In fact, many theories and treatments for drug abuse ignore family history and intergenerational dynamics altogether. Contextual therapy (CT), in contrast, offers a conceptual and clinical framework for understanding how social, intergenerational, and nuclear family dynamics contribute to the patterns that produce and maintain drug addiction (12, 13, 18). CT views addiction as a problem embedded in a particular social context that has deleterious consequences for the individual, the family, and society. At the center of the problem is the deprivation of parenting, which creates a "fixed expectation of unfairness in the world" (18, p. 520). As Cotroneo and Krasner (18) point out, this deprivation represents an "unfinished business" that the problemed person continues to reconstitute by "holding the world accountable for what was not received from family members" (p. 520) or from society itself. Thus, addiction is a means through which an individual can obtain reliable, albeit synthetic parental nourishment. An addiction may also serve the function of helping family members confront the integrity of their relationships. A consequence of the sacrificing behavior of the addict is that parents and adults in positions of authority vis-à-vis minors are often held accountable (18, 30). In this paradoxical manner, the addict is invisibly loyal to the familycontributing to family unity through symptomatic behaviorwhile forcing a confrontation of "socioethical" (21) issues. Furthermore, as noted by a number of authors (15, 17, 27, 28, 30), when the cost of individuation in one's family of origin is too great, substance abuse may provide a false sense of independence to the degree that it contradicts parental demands. On the one hand, while the abuse of a substance may provide a temporary sense of freedom and ecstasy, on the other hand, the dysfunctional behavior places addicts in a position of dependency. It is here that the paradox is constituted. By being pseudo-independent, addicts becomes dependent; by not giving in to the demands of others, they sacrifice themselves to others, to the trans-generational transgenerational system in which they are enmeshed. If the dependency is an addict's way of giving, this compounds the dynamics of invisible loyalty to the family. Additionally, the repetition of these dysfunctional patterns of relating sabotages the addict's attempt to create his or her own family. The addict's spouse complements these dynamics with patterns of actions that maintain loyalty to the spouse's own family of origin.1 In this article, we present a case study to illustrate basic concepts of CT, the process of therapy, clinical interventions, and an emerging contextual-intergenerational approach to drug abuse. The case presented below was part of a pilot study from a larger 3-year treatment outcome investigation of the impact of CT on drug abuse problems (see 6).2
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BASIC NOTIONS OF CONTEXTUAL THERAPY The theoretical basis of CT has been the focus of a number of recent volumes (11, 12, 13) and articles (1, 4, 5, 9, 10, 18, 19, 21). Therefore, we will limit the discussion of the theoretical framework to several basic concepts of CT and an illustration of their practical applications. CT orders relational reality into four key dimensions: the facts of one's life, a person's individual psychology, systems of transactional patterns, and merited trust (11). Each dimension constitutes a realm of reality. Briefly, the dimension of facts considers the realm of material reality such as physical, social, biologic, and economic aspects of life (2, 7). The dimension of psychology refers to the interior world of the person, as well as to motivational considerations, which may be understood from a variety of personality theories (for example, cognitive, behavioral, and psychodynamic). The dimension of transactional systems refers to the person as part of the greater wholethe family. Thus, systemic concepts such as organization, structure, hierarchy, self-regulation, feedback, among others, are important resources in understanding family relationships. The fourth dimension of merited trust is, perhaps, the major contribution of the contextual approach; this socioethical (21) dimension of giving due consideration addresses issues of trust and fairness as the core component and motivation of relational life. Promoting dialogues among family members, whereby the fairness of each other's position is openly examined, replaces blame with understanding. Offering credit to family members for their contributions to family life acknowledges that all members did their best, given their contextual determinants. From this position, trust can reenter the relationship. Since trust is essential for the negotiation of a fair relationship, the CT therapist uses the building of trust as his or her most powerful, curative and preventive intervention. The following case illustrates how the therapists worked at establishing a dialogue of trust and support with a couple in which the husband was addicted to drugs. The therapeutic effort was guided by an overall strategy to help each person face the fairness of each other's position.
THE COUPLE Steven, age 35, and Claudia, age 29, came to therapy3 2 weeks before their marriage for help with Steven's drug use and to clarify marital problems. Together they managed an apartment building. He worked extra hours in sales while she attended school. Steven had used drugs since his early teens and had been in and out of methadone treatment programs for the last 7 years. He was an only child and described his mother as overprotective and domineering. His father, to whom he felt closer, was presented as a more easy-going person. Steven had been married before but divorced after 1 year. Claudia too was an only child. She had a paternal half-sister who died at age 17 in a car accident when Claudia was 7 years old. Claudia's father died under mysterious and tragic circumstances. The family suspected suicide. According to Claudia, her father was a cold and detached person with a history of numerous separations and losses. Claudia viewed her mother as a talented but submissive woman with limited aspirations and longings to be nurtured. Claudia portrayed her maternal grandmother as a domineering and manipulative woman who continued to exert a great deal of influence on her family.
THE THERAPY The treatment consisted of 10 interviews over a 6-month period. The therapeutic process can be divided into four stages: (a) identification of needs and resources; (b) exploring intergenerational patterns; (c) fairness and accountability; and (d) earned credit and the establishment of trust.
Stage 1: Identification of Needs and Resources Identification of needs occurred during the first and second sessions. In the first session, the couple identified a number of needs and problems to work on during therapy: (a) lack of trust, (b) difficulties communicating with each other, (c) difficult relationships with their respective families of origin, (d) Steven's irresponsibility, and (f) Claudia's stubbornness. The first session also dealt with plans and expectations regarding the wedding. Given these concerns, the therapeutic goals were to help the couple: (a) reach an ethical balance in their relationship based on fairness and recognition of obligations and entitlements, (b) build or restore trust, (c) reduce or eliminate drug abuse symptoms, and (d) find more constructive ways to allow the couple to express loyalty to their families of origin. The second session focused on events connected with the wedding, which for Steven represented a statement of commitment to his fiancee and a celebration with family and friends. Steven's success at holding two jobs, one as a building manager and the other as a salesperson, also signified a commitment to himself and the health of the relationship. For her part, Claudia was working and had begun to take several college courses. These were all important resources for the couple.
Stage 2: Exploring Intergenerational Patterns
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The third, fourth, and fifth sessions focused on exploring current and past intergenerational patterns. In the current or horizontal plane, Steven expressed resentment and anger about Claudia's controlling attitudes. He demanded recognition and acknowledgment from her for his efforts at revindication. Claudia in turn, complained that Steven was irresponsible, dishonest, and continued to exploit her. She expressed resentment and fear that he would either betray and abandon or, worse, continue exploiting her. Their dynamics were then explored as complementary repetitions of relational strategies learned in their families of origin. The therapists gave recognition to both clients for the contributions each were making to their parents, but also questioned the consequences of continuing these dynamics with each other. The therapist stressed the importance of settling old family accounts in order to free the couple from destructive roles and to enable them to improve trust and fairness in their own relationship.
Stage 3: Fairness and Accountability In sessions six, seven, and eight, the therapy dealt with issues of accountability and fairness. By negotiating tasks in and out of sessions, the couple began to take more responsibility for defining their own relational rules, rather than relying on those learned in their family. They also found that through a process of compromise, they could establish new levels of fairness in the relationship.
Stage 4: Earned Credit and Trust In the final stage of therapy, sessions nine and ten, the couple began to reestablish trust through the acknowledgment and crediting of each other's efforts in maintaining and improving the relationship. The therapists encouraged a dialogue that helped the couple find ways of rebalancing the injustices of the past through constructive give-and-take in the present and future.
PROCESS IN CONTEXTUAL COUPLE'S THERAPY In the early phases of therapy, the therapists helped the couple to understand the dysfunctional, complementary patterns of their relationship (3). This was going to be a marriage between two people who had been parentified as children. Although each functioned very differently in their families, both were helpful in ways that were beyond the responsibility of a child. Steven was parentified as the family scapegoat; his apparent failures and seemingly irresponsible and incompetent behaviors served a central function in the family. Alternatively, Claudia had a history of being the strength and support of the family, resuming caring for her mother when her father died. As adults, both Steve and Claudia's complementary, parentified roles constituted a core dysfunctional pattern in the relationship. Steven's seeming incompetence became an open invitation for Claudia's apparent dominance, while Claudia's need to be in control reinforced Steven's seeming dependency. In this way, though they resented one another, each offered what the other wanted and needed in order to remain invisibly loyal to their families of origin.
Intergenerational Exploration During the following segment from the fourth therapy session, the couple began to reflect on how caretaking was a major issue in their relationship: Steven: Okay. I like to be taken care of. I can get into a situation where I am totally dependent on you. Like this morning, you built up this whole scenario. I was late getting started, okay. But then you get me with "the lobby is not going to get done if you do not do it before one o'clock," which is bull. So you start a fight with me. You take the vacuum cleaner, drag it downstairs, complaining that you will get calluses on your arms or something. Like I am making you do all this work. Then you sit down and you talk about me being responsible. I felt like you were taking all my responsibility away. You want me to be responsible and do these things. Yet you manipulate how things are done. In the systemic dimension, both Steven and Claudia support each other's behavior. Steven's dependent attitude prompts controlling behaviors from Claudia. He complains that he needs to be delegated more responsibility, but then fails to honor those commitments. Claudia, in turn, with her need for overresponsibility, maintains Steven in an incompetent position. She demands that he be responsible, but then sabotages his efforts. Covertly she tells him, "You are not able to care for yourself; you need me to do things for you." While these roles are seen as dysfunctional, their positive nature must be pointed out. In part, the willingness to continue these dynamics is each person's way of offering what one thinks the other needs and wants. Though dysfunctional, it is one way to remain in a relationship with someone. Furthermore, their awareness and dissatisfaction with these roles can be important resources for the therapist. Steven express his willingness to face these issues toward the end of their argument. The following statement set the groundwork for a dialogue wherein family members began to examine their behaviors and reflect on the ethic of due consideration: 3
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Steven:
Anyway, I'm afraid that if I do not allow you to take care of me in a certain way, that you will be unhappy and not be able to handle it ... I'm really afraid that if I act one hundred percent responsible and together, that it will create a gap in our relationship. This statement characterizes the loyalty bind in which addicts are often caught. A demonstration of independence and initiative by the addict might cost him or her the relationship, yet the only acceptable role in the relationship is one of dependency. This dependency, however, was an important means of Steven's giving to his wife who, in turn, gives through her assertive and directive behavior. However, here the reality of the factual dimension reinforces the dysfunctional systemic dynamic. Were the wife to take a more passive role and wait for her husband to show initiative, their economic survival might be compromised. While these themes could be worked on in the context of the current generation, the therapists' sensitivity to the intergenerational context and awareness of loyalty issues in relation to the family of origin guided the treatment process. A challenge to the current generational patterns of relating without an appreciation of the intergenerational loyalty dynamics may produce only an ephemeral change. If this dimension is not addressed, the potential disloyalty to the prior generation may inhibit change in the current generation. In our practice of CT, we have found it helpful to move "vertically," that is, up the intergenerational lines, once the couple fully articulates the core conflict in the horizontal or current generation. A crucial therapeutic task is to help the couple explore how intergenerational issues contribute to their present predicament. The following segment from the fourth session illustrates the method of vertical movement, which invites the members of the family to reflect on their past relationships while continuing an atmosphere of open dialogue: Therapist: Let me ask you something. You recognize this is something almost like a pattern with you. There is the potential of you becoming more and more seemingly irresponsible. Steven: Yeah. There is a potential that ... Therapist: There is a potential in that she [wife] becomes overly responsible. And then she gets to take on things that normally you should be doing. Steven: Unhunh. Therapist: Is this something that has happened to you before? Steven: Unhunh. Therapist: Who has it happened with? Steven: Well, I mean, in my whole family. My parents to this day do not think I can probably dress myself. Therapist: You have been the seemingly irresponsible one in your family. Steven: Yeah Therapist: Who took care of you when you were living with your parents? Steven: My mother, my father. Well actually, mostly my mother. Therapist: Mostly your mother. What did she do? Or what does she do? Steven: Just takes over everything. This dialogue not only exposed the complex relational weave of current and past generational life, but it also illuminated how drug abuse may be connected to loyalty conflicts originating in the family of origin. In the above sequences, Steven revealed the bind of having only two relational options in his family, both of which had negative consequences. If he sought independence, his parents threatened him with abandonment. If he wanted to remain in the relationship, he was forced into submission. The first option would leave him relationally isolated, while the second one required a denial of self-responsibility. Given these two alternatives, a child will generally chose "relatedness," since she or he depends on the parents for biological survival as well as psychological and existential identity (19). Therefore, loyalty become the means by which one remains in relationship. However, when the degree of loyalty necessary to remain in relationship become exploitative, children suffer severe consequences. Relational injustice profoundly affects a child's later ability to negotiate a give-and-take in adult relationships. Boszormenyi-Nagy (11) suggests that when a child has been denied the right to fair relationship, she or he becomes over-entitled, and therefore justified in exploiting others. Further, when one's entitlement is so depleted that one no longer feels hurt or infuriated by the injustice, the exploitation turns in against the self. Heroin then is a solution to this dilemma. It provides both the euphoria, a desperate attempt at relational satisfaction, and the self-destructive infliction on one's undeserving, worthless self.
Intergenerational Complementarity Claudia, though not struggling with problems of substance abuse, brought to the relationship her own historical web. As Bowen (14) suggested, people seek out mates at similar levels of development (differentiation) as themselves. An understanding of Claudia's legacies and loyalty issues help clarify how she could sustain a relationship that appeared so dissatisfying. In the next sequence, the therapist asked Claudia to examine her part of the caretaking in the relationship:
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Therapist:
Do you see what he is saying? Because you seem to offer help in the same way his mother did. You say, "Either I do it or I don't help at all." Where did you learn that? Claudia: From my father. Therapist: What did he do? Claudia: Just that. The same way I do it. Therapist: To who? Claudia: To my mother. I immediately think of Christmas. Every year my parents gave this party. And my father always felt that it was my mother's party. He would take care of the booze, but the rest of the party was her responsibility. My mother always wanted him to enjoy it, but he felt it wasn't his party. Therapist: So he washed his hands of it. Claudia: Yeah. I think ... I don't think that I ever ... (sigh) What I want to say is that I feel it is either my show and I'm in charge or it is his show and I'm not sure I want to be involved. In the same session, Claudia revealed how her own victimization by her father's unpredictable behavior contributed to and justified her entitlement to repeat these destructive behaviors with Steven and other men in her life. She too was in a loyalty bind. If she acknowledged her mistreatment of Steven, then she must also take stock of her disappointment with her father. Falsely exonerating her father by following in his relational footsteps kept her invisibly loyal to him while, in the psychological dimension, warding off the pain of that disappointment. Through this dialogue (in the fourth session), the therapists expanded the relational reality of the couple to account for factual, psychological, systemic, and ethical forces that contributed to their relationships. Claudia and Steven were able to reflect on how experiences in their families had cultivated relational templates that were being repeated in their relationship as a couple.
Fairness and Accountability Understanding the psychological and ethical dimensions of relationship broadened the couple's view of their current problems. However, these clients needed to work out specific changes in the context of present, ongoing relationships; reflection must be linked to action (4). In session five, the therapists introduced new relational possibilities, using the couple's new-found understanding, into the center of their conflicts. The therapists asked the couple to carry out an argument at home and later to reflect on how each of them participated in the fight. The following segment of dialogue occurred in the sixth session at the conclusion of their discussion. Claudia: Well I thought it was pretty interesting. In fact, I realized that what we argue about is not the work. Most of our arguments are really about money, but it's too touchy a subject to discuss directly. So while our arguments get resolved, neither of us feels very satisfied afterwards. We apologize and make up, but we never resolve the issues themselves. Steven: What was hard for me was the idea of compromising. I am afraid that I might not get what I want, or I might find out I'm wrong. So I don't listen to her and she doesn't listen to me at certain points. Claudia: And you think that if you listen to me that maybe we'll have to do it my way. But it is never "our" way. It is your way or my way. Steven: Yeah. But I'm a little confused now about what I want to be in charge of and what I don't want to be in charge of. One day I wake up and say, "Claudia, I'm the manager. You're going to school. Go have fun and go out with your professors and do all those things." And then other days, I'll wake up and say, "Gee, I need help. Come on, let's get together. Will you help me plan all this out?" Therapist: And that is exactly what you are struggling with. Who is going to be the manager of your relationship? Are you going to be manager or is Claudia going to be the manager of both of you? Or are you going to be co-managers? Who's going to be in charge? In this segment, rather than pushing the couple into a new behavioral sequences, the therapist asked the couple to consider what is fair and beneficial in the relationship. The issue of power in the relationship was reconsidered from the dimension of the ethics of giving due consideration, recognizing that honest and fair negotiations are in everyone's interest. The problem became how they as a family were best going to organize their relationship such that both could feel respected and responsible. In the above segment, the therapists continued to expand these relational dynamics by introducing previous intergenerational themes in the form of challenging questions. The therapists asked: "Whose rule are you going to have? Are you going to have the rules from Stevens's or Claudia's family, or can you create new rules for your relationship?" The constant interplay of vertical and horizontal dimensions represented an important resource in this model of therapy.
Earned Credit and the Reestablishment of Trust
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By the ninth session, the couple reported that things were going well. Specifically, communication and trust had improved, and the distribution of tasks in managing of the apartment building was going smoother: Therapist: What are you able to talk about now that you couldn't before? Steven: Well everything. How I'm feeling and what I want to do, what my plans are to get it done. All of that. We made a commitment that I wasn't going to be distant and cut-off, and she is not going to be overly emotional, yelling and screaming. When that happens, I just don't want to be involved. So as a result, (to wife) I feel like I can trust you. We work more as a team. Claudia: Reciprocity. Therapist: There is more give and take? Steven: Yeah and I think it is great. Steven also reported that things were going much better with his mother. He said that she seemed to have let go of him and was treating him more as an adult. Steven's only explanation of this was that Claudia had been good with his mother. This initiated an important dialogue in which Steven began to acknowledge what Claudia had done for him during the first years of their relationship. This not only worked to reestablish trust in the relationship, but also helped Claudia face her reasons for staying in it. The next segment began with Steven telling a long story about his addiction and how Claudia had remained with him through very difficult times: Therapist: ... and she stuck by you during all this time? Steven: Yep. Therapist: That is a long time. Claudia, what do you think of this? Because that was a very important thing that you did. Claudia: Well I knew that he could do it and that he wanted to do it. I kept thinking it was...only a question of months. Therapist: And then it got prolonged to two years. You were in a position of giving to him for a very long time. He was really crippled. How did you do that? Claudia: Well, actually, I know perfectly well why I did it. You see, when I was living in Texas, I had been with another Steven who was an artist that drank too much. A lot of the same run-around. Finally I gave up and left. But I always felt that I never saw things through. So I think I have stayed with Steven because it was the same situation, a very talented man that, if straightened out, would be an incredible person. With probing from the therapist, Claudia took one step further and realized that she felt she had deserted her father at the time when he committed suicide. Understanding this further reduced Claudia's resentment toward Steven. However, in the context of their relationship they both still felt that somehow Steven now owed her something: Therapist: I think that you are entitled to some things from him, by virtue of what you have been giving him. Steven: And she's getting some of it. Therapist: And she should get it. By all means. The issue is, what should you get that will be fair for both of you? How can you collect from him in a way that is less destructive than how he received from you? Claudia: Oh, I wouldn't do that. Therapist: I would hope not. But many people do. They destructively reclaim what they think they are owed. So, how can he constructively rebalance things with you? Claudia: Well for openers, I have to deal with my resentment. I'm able to control that most of the time now. So what I feel I deserve is to have some of the promises he has given me. Therapist: Which are? Claudia: A lot of things we've been talking about here. Staying clean, being honest with me, working together, not protecting me from his problems. Therapist: (to Steven) How do you feel about that? Steven: I think she deserves that anyway. Period! That is just ground zero. Paying her back doesn't even include that. When I first met her two years ago, she was working two jobs and going to school and struggling with me. I can't believe how this woman did it. So now she is working one job, and we are working together on the building, and she is going to school. So it's still rough but not as bad. And if I can eventually swing it, she'll be able to just go to school like she wanted to do. Strange as it seems, she has two years left. The above segments illustrate the couple's progress in their efforts to restore trust in their relationship. Steven was able to acknowledge that he had received a great deal from Claudia during a time when he needed support. He feared that now, when he was trying to pay her back, she was getting even and sabotaging his efforts. Claudia, in turn, feared that Steven was going to continue exploiting her or would eventually betray and abandon her. Instead of focusing on Claudia's pathology, co-dependence, or bizarre psychological reasons for helping Steven, the therapists introduced the ethical dimension of merited trust. Independent of whatever psychological reasons she had, the
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fact remained that Claudia had given to Steven in important ways.4 Once the couple recognized and acknowledged mutual entitlements and obligations, they were able to define what was fair in their relationship. Claudia expressed her entitlement to expect Steven to be responsible, stay away from drugs, and be honest with her. Steven agreed that she had given to him in important ways and deserved what she was asking for, and even more. He noted that he was trying to pay her back through honesty and responsible actions, and by contributing to the financial support of the family, thus giving her an opportunity to attend school. The couple began to elaborate a concrete way to balance debts in the relationship.
FOLLOWUP Eighteen months after the 10 therapy sessions, Steven continued in the methadone program; this was the longest period of time he had remained in a drug treatment program. He was clean of illicit drug use and managed to gradually reduce his dose of methadone by about 80% from what it had been at the start of couple's therapy. Furthermore, he continued to work two jobs and reported major improvements in his relationships with his family of origin. Specifically, during an automobile accident involving his father, the parents asked Steven for help in running the family business. This request for help was an important step in reestablishing a trust-based relation with his family of origin. For her part, Claudia continued to work and study, and she initiated a number of reconciliating steps toward her mother and grandmother. She began to visit her mother more frequently and, for the first time, began discussions with her mother about the death of her sister and father. At this time, the couple requested further consultations, which were granted.
DISCUSSION AND CONCLUSIONS The CT approach is principally oriented toward working with individuals, couples, and families on a socioethical dimension promoting trust-building dialogues. Change is considered a dynamic, multilateral progression between conflicts of interest, on the one hand, and reflection linked to action, on the other hand. As in the case presented above, directly addressing conflicts of interest in terms of specific burdens and merits for Steven and Claudia led to concrete plans of action that contributed to the building of trust in their relationship. Dialogues supported in CT represent a dialectic between reflection and action (1, 4). Indeed, the level of action of CT, while not oriented toward insight, may appear as such in that clients are invited to reflect on their historical context and reach conclusions as to how their context affected their current relationship. This process of reflection is illustrated in the phases we have termed as intergenerational exploration and intergenerational complementarity with the couple in therapy. However, reflection and insight alone, without a commitment to action, too often remain doomed to rhetorical self-questioning. Alternatively, while CT is not necessarily oriented toward strategic, structural, or communicational changes, it may appear as such to the extent that clients are encouraged (or challenged) in a variety of ways to consider the consequences of maintaining the status quo for themselves, their family, and posterity. With Stephen and Claudia, the therapists appeared to be working at a transactional level (during the phase of fairness and accountability) when tasks were assigned and interventions made to halt their interactional process. However, structural-strategic-transactional actions, without reflection on the family, community, social, and political context, borders on (at best) activism and (at worst) frenetic action. Careful attention to the dialectic between reflection in the service of action and action in the service of reflection is an essential aspect of the contextual approach. Contextual therapy offers conceptual and methodological tools for understanding and working with the problems of drug abuse. The case presented above illustrated the complex weave of factual, psychological, systemic, and socioethical dimensions that characterize the relational dynamics underlying drug use and addiction. Helping addicts and their spouses face the relational dilemmas rooted in the family of origin5 sets the context for facing issues of integrity and fairness in current family relationships, which may be associated with the addiction. Thus, the level of action of CT is socioethical. The CT therapist is concerned with promoting freedom from distorted and corrupt relations, rather than with the mere management of addictive behaviors (18). This freeing begins with the acknowledgment of relational injustices and with the offering of credit for contributions made by all family members. Understanding the injustices in their proper social and economic context is another aspect of acknowledgement and reflection. Such therapeutic action facilitates a redistribution of accountability for past inequities and the shared responsibility for future action, thus contributing to mutually confirming dialogues (11, 21). Indeed, it is through dialogues based on trust, fairness, and accountability that it becomes possible for a family to reverse an addiction, since it may no longer be necessary to receive nurturing, trust, and parenting through a chemical substance and other substitutes for what never was: the illusion of a complementarity between two whereby their otherness is annulled to produce a one. Through such dialogues, a process of liberation and empowerment can be initiated.
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Manuscript received October 6, 1988; Revisions submitted March 8, 1989; Accepted April 21, 1989. 1While drug abuse is certainly not the only solution to individuation from the family of origin or to the socioethical dilemma of
exploitation, the deprivation of parental caring in conjunction with a particular social context (for example, availability of drugs, peer influences, ideology of immediate symptom relief) maximizes the likelihood of a drug abuse outcome. 2The results from the treatment outcome study provide data on the effectiveness of the brief CT intervention in comparison to a
psychoeducational modality. Details on the methods used to evaluate multiple levels of outcome (for the identified patient, other family members, couple, and family), recruitment, attrition, treatment compliance and fidelity, and the instruments employed, are available from the first author. 3The family was referred for treatment from a methadone clinic and was a preliminary case used, in part, to test the instruments for a research study. This family was not charged for the therapy and all 10 sessions were videotaped. The names and some facts have been changed to insure anonymity. The cotherapists in the case were the first and second authors. 4Indirectly, however, the relationship with Stephen gave Claudia an opportunity to resurrect a dead man who had not been hers and who could now be hers. While this dynamic partly explore why Claudia continued to struggle in a seemingly unsatisfactory marital relationship, we decided to postpone an examination of her complementary side and focus on what she could receive directly from Stephen. 5While CT concepts are certainly useful in conceptualizing social processes linked to drug abuse, in this article we have chosen
to focus more on family-couple and less on community-social, larger system dynamics. A number of useful critiques of family therapy (8, 20, 21, 24, 31) are available for a further elaboration of these issues.
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