Self-help

Frequently asked questions and issues raised by therapists

I manage to get significant others to attend once or twice but I find it difficult to keep them engaged in the sessions.

It is important to make very clear the purpose of the involvement of significant others as part of the SBNT sessions. Sometimes, therapists, particularly when they start using the intervention are able to invite network members initially and are very successful in getting them to attend a session. If the purpose of the network member's attendance is not made very clear, however, the likely result is that the network member will start doubting whether he/she can make any contribution to the progress of the focal person and either stop coming or start questioning whether it is useful for him/her to be involved at all. Network member's involvement however, is central to the success of the treatment and as such is extremely important. In our experience, we have found that sometimes, therapists assume that network members understand the purpose of network members' involvement and therefore this is not fully discussed. In reality, they need guidance from the therapist who operates as a team leader, as to what their role and contribution to the treatment process can be. As a therapist you should always ask yourself at the end of a session during which you engaged a network member whether you have clearly described the purpose of his/her involvement. It may be useful to recap at the end of a session by saying something like:

As we have discussed, the way in which this treatment works is by enhancing/increasing the positive support for change that people have while they are attempting the difficult task of changing their substance use and to try to ensure that this support remains in place for the future. In order to achieve this we need to work directly with all those people who are prepared to offer support and so your attendance at the meetings is extremely important and useful. We are a team with a clear task: to actively support the focal person's attempts to change drinking/drug use by identifying things that we can do both over the next few weeks but also in the future'

Encourage network members to ask questions and clarify any doubts they may have about their attendance. Remember that for someone who has never been involved in any form of addiction treatment, the experience of being in a room trying to support a close relative or friend with a drinking/drug problem may be unusual. Your task as a therapist and therefore a team leader while delivering SBNT is that network members walk out of the session feeling that they have something positive to offer and therefore are willing to come back to the subsequent sessions.

I find that sometimes I end up talking mainly to the focal person. It feels like I am doing one to one treatments in the presence of other people.

Part of the task in SBNT is to make sure that everyone is involved in some way in the change process. In certain situations you may find that because of the characteristics of the people involved, one member of the group, sometimes the focal person, sometimes a network member, monopolises the discussion and after a short while you end up feeling that you are only interacting with one person in a room where other people are present. It is important to try to avoid this situation as it may lead to drop out from either the focal person or network members who do not feel involved. One way to avoid this situation is to make sure that you ask everyone present to contribute to the discussion at regular intervals. Make sure you acknowledge any statement made by someone however brief and remember that the essence of the approach is that network members will be able to help the focal person now and in the future. Part of your role is therefore to lay the foundations for this to occur by creating a process whereby everyone is involved and feels part of a team. Ask questions such as 'What did you think of that?' 'Have you experienced this situation?' 'Can you think of examples of this?' It must be difficult for everyone when that happens, what do you think?'

At times, I find myself talking too much. It feels more like teaching than leading or facilitating.

It is not uncommon to fall into the trap of providing too much information, without creating the opportunity for the group to discuss the material and relate it to their experience. This is also likely to happen when the group is rather uncertain of the process or made up of people who are quiet. One rule that can be helpful in order to avoid this is never to introduce more than one concept at a time without discussing it with the group and seeking examples from those present as to how this concept relates to their experience. Always when you introduce a concept you could ask those present to think about ways in which they experienced this in the past. This will also help you to check that everyone has understood the information. For example if you are talking about coping, when you introduce a coping style, e.g. tolerance, you could ask the group to think of examples from their own experience of tolerant coping before you move on to introduce a second coping style. In this way you will be alternating the introduction of new material with discussion and engagement of those present in the session. You will also guarantee that everyone understands the theory in a way that makes it relevant to their own experience.

SBNT is different when you do not have a network.

SBNT may look and indeed feel different when you do not have a network. The philosophy however can be applied whether you have managed to engage a network or not. Your ultimate aim is the same, namely to maximise the positive support for change that someone attempting to change his/her drinking/drug use has. Sometimes you can start this process with network members in the room but on other occasions you may be able to initiate that process successfully for a client, yet you may not have managed to engage anyone in the treatment sessions. Refer to the diagram earlier on the manual describing the three possible strands of SBNT and if you are unsure, discuss the particular case with your supervisor.

I can understand the philosophy of SBNT even when you are only working with the focal person but sometimes I find myself stuck, going repeatedly over the same ground and trying to convince the focal person to invite a network member sometimes even detecting some resistance.

This is a good sign that new strategies need to be tried and more often than not these strategies will involve being a very 'active agent'. Be prepared to meet the focal person at home for the next session if that is going to maximise the chances of engaging a partner or other family member. If soon into the session you find yourself in a discussion where you are trying to convince the focal person and he/she comes up with barriers, you could suggest that you could spend the rest of the time available going to meet the network member or talking to the network member on the telephone or composing a letter. As a rule, do not allow yourself to spend too long debating the difficulties in engaging a network member. Try to do something positive to help the focal person to achieve the task rather than getting drawn into his/her own difficulties. Remember that the emphasis is on doing rather than talking.

Sometimes I feel as if I am in the middle of a battleground and the whole meeting seems to drift away from my control

In SBNT this is a clear sign that something has gone wrong and this can result from a number of different problems: the wrong network members. Sometimes, in discussion with the focal person you may have identified a network member and managed to engage this person in the sessions. You may later find that the network member is using the session to vent his/her anger at the focal person in a way that does not allow you to meet the aims of SBNT. A father may be extremely angry with his son, a wife with her husband. These are normal feelings and understandable but they need to be left aside during SBNT so that the focus is on positive support not criticism or 'confrontation'. It is easier to anticipate these situations and avoid them rather than deal with them once you are within a session. Take care during the first session to spend enough time exploring with the focal person whether a particular potential network member is going to be helpful and supportive in the sessions. Remember that your main criterion for choosing network members is that they will support the focal person. If you have not managed to avoid this situation and criticism surfaces during the session make sure that you re-state clearly and as often as required the purpose for the meeting 'to increase positive support for change'. Try to stop negative interactions as soon as they emerge, do not let the criticism go on for any length of time, once you identify this situation, deal with it promptly.

The wrong focus. It is not uncommon, particularly when feelings are high to lose the focus of the session and for negative interactions to emerge quickly. Promptly try to bring the focus back to the notion of positive support. State that you understand how people are feeling and how common it is for alcohol and drug problems to give rise to these feelings but how important it is to develop positive support if the aim of maximising the chances of success is to be achieved. If possible, try to work with those network members that are positive and use them as models for the other members.

Sometimes it feels as if I am conducting couples' therapy. Is this useful for SBNT?

SBNT is different from both marital and family therapies. Some of the key distinctions are outlined in the manual. Sometimes, when you are working with a couple and particularly if thereis acertaindegreeof conflict intherelationship, you mayfindyourselftrying toexplore the relationship difficulties within the session. This is not the focus of SBNT and therefore this type of work should not be conducted as part of the treatment. The focus is very clear and specific: 'to elicit positive support for change'. Problems can be explored only if they interfere with the ability of someone to provide this positive support but any significant relationship problems cannot be dealt with wit