Support Network Intervention Team: A Key Component of a Comprehensive Approach to Family-Based Substance Abuse Treatment

Abstract

The Support Network Intervention Team (SNIT) is an approach designed to assist multi-agency-involved families with a variety of issues. The SNIT provides structure helpful to a family addressing issues resulting from substance abuse. It is a strength-based approach that invites the family system to include a variety of support persons along with their professional helpers. This intervention is part of a comprehensive approach to family-based substance abuse treatment. This article explores issues of development and implementation of this approach. Typical issues and concerns in such an approach are also discussed. A case report is provided for clarity and illustration.

KEYWORDS:

• addiction
• family therapy
• interventions
• recovery
• support network

INTRODUCTION

The Support Network Intervention Team (SNIT) is an integral part of a comprehensive approach to family-based substance abuse treatment. It is a team-based intervention designed to assist multi-agency-involved families with a variety of issues. The SNIT is a strength-based approach that invites the family system to include, along with their professional helpers, all who are vested in the family's recovery. It is designed to surround the client in a network of professionals and nonprofessionals who care about the client and the outcome of their treatment. The network provides a structure which is able to assist the family as they address their difficulties. This structure also provides a forum to create a unified coordinated plan of care. SNIT meetings are structured team meetings designed to advance the client's treatment.

The SNIT is part of a larger experimental substance abuse treatment program that is a joint venture between Appalachian State University and New River Behavioral Health Care. This project has been reviewed and approved by the Appalachian State University Institutional Review Board.

THEORETICAL ORIENTATION

The SNIT approach is part of a family-based, child-centered systemic treatment program. It views addiction as not only a personal issue but intricately interconnected to the family and other significant systems. Research indicates that family engagement in the treatment of substance abuse is positively related to the client's engagement and retention in treatment (Rowe & Liddle, 2003; Stanton & Shadish, 1997). Further, the extent to which the family becomes involved in treatment is partially dependent on the therapists' active initiation and pursuit of their involvement. Not only is the entire family affected by the addiction, but the family is also able to provide unique leverage in treatment that is missed otherwise. A meta-analysis of family therapy approaches for drug abuse, found that clients who participated in family interventions showed significantly better results with recovery than those in other interventions that did not involve the family (Stanton & Shadish).

In line with these findings, an integral part of the SNIT philosophy maintains that a child of a parent who is using drugs is a child with a drug problem. This approach draws from four systemic theoretical orientations: strategic, solution focused, structural, and experiential. These theoretical orientations contribute key assumptions to SNIT implementation with families who have an addicted member.

Strategic therapy based on the work of Haley (1976) views the therapist as directly responsible for change within the client system. Strategic therapy has been integrated with structural family therapy and applied to substance abuse by Stanton, Todd, and associates (1982). This sets up a therapy that calls for the clinician's primary involvement in the clients' attempts to solve their problems. Given this, the therapist takes a very active role in treatment and initiates SNIT meetings as needed. During the meetings, the therapist provides the meeting agenda and facilitates productive interactions amongst SNIT members. Strategically, the focus of the meeting is solving problems and accessing necessary resources.

Closely related to the strategic approach is the solution-focused perspective which has recently been successfully applied to substance abuse treatment (Berg & Miller, 1992; Juhnke & Coker, 1997; Mason, Chandler, & Grasso, 1996; McCollum & Trepper, 2001; Miller & Berg, 1995). This approach is largely ahistorical, focusing on how clients can solve specifically defined problems in their lives. Rather than focusing on client deficiencies, the solution-focused approach is strength based. The same is true in a SNIT; the focus is on using client and family strengths in problem-solving as the client families move along the path to recovery. This is evident in the positively worded questions that are asked during each SNIT, including: What are some of this person's (family's) strengths? What supports are you currently giving? Are there any other supports you could offer? The solution-focused approach has been shown to be an empirically validated approach to working with substance abusers in an outpatient setting (Smock et al., 2008).

Structural family therapy (Minuchin, 1974; Minuchin & Fishman, 1981) contributes to the SNIT's focus on the relationship between structure and function within family systems. Substance abuse is correlated with dysfunctional and ambiguous family structures. Within this approach, the team proactively intervenes to alter dysfunctional family structures, build more functional structures, and reinforce those structures once established. This involves continual and adaptive direction from the therapy team and the support network.

If children are present in the addict system, it can be assumed that their subsystem has been influenced by the dysfunctional structures of the addictive system, often with loose boundaries and parentification. For this reason, children are involved in SNIT, with one of the ground rules in a SNIT being, “Remember, children are listening.” This sets a model for the family about appropriate behavior in front of children. There is an emphasis in a SNIT of the parent reclaiming the parent role, so that the child can reclaim the child role, thus establishing appropriate hierarchy to facilitate healthy family functioning.

Finally, experiential therapy (Keith & Whitaker, 1982; Whitaker & Bumberry, 1988) contributes several key concepts to the SNIT. Consistent with this theoretical orientation, crises are not viewed as problematic but as growth opportunities. The SNIT response to client crises is to convene a SNIT meeting and use the natural energy around that crisis to create change in the family system. In addition, experiential family therapy assumes that families need role flexibility, not rigid dysfunctional structures. The SNIT allows for the treatment team and the family to use flexible, creative structures to meet their needs and solve their problems.

FAMILY NETWORKS

The SNIT shares conceptual commonality with family networks. The use of family networks dates back to the early 1970s in the work of Speck and Attneave (1973). Their treatment involved calling people to work with the family of an identified patient as a group, at times including more than 50 individuals, to allow “… the group to renew itself: the experience of retribalization” (Speck & Attneave, p. 19). The process of retribalization helps move the locus of the difficulty out of the addict and back into the system or tribe. In our work with addicted families, we have found that family systems of substance abusers tend to break down and become chaotic. This is evidenced by dysfunctional rules and negative patterns of interaction that occur within these families. “The goal of network interventions is to utilize the power of the assembled network rapidly to shake up a rigidified system in order to allow changes to occur that the members of the system, with increased knowledge and insight into their predicaments, would wish to occur—and for which they are responsible” (Speck & Attneave, p. 7).

Galanter (1993) used networks as an intervention to address alcohol and drug abuse. He found that a network can be useful in addressing the distortion and denial that universally exists in substance addiction. Galanter concluded, “A social network is apparently necessary for stabilizing the cognitive components of the patients' recovery, for allowing them to deal with a new reality, and for providing the essential support for accepting the new reality.” (p. 15.) He identified the forces of cohesiveness, cognition, and coercion as being the social forces that shape the effectiveness of the treatment network.

Another interesting network-based approach was developed by Hamilton, Brantley, Tims, Angelovich, & McDougall (2001), called the Family Support Network which has been widely adopted and is supported by the U.S. Department of Health and Human Services under the Cannabis Youth Treatment Project Cooperative Agreement. It was designed to target adolescent cannabis use through active family involvement. Dennis et al. (2004) empirically validated this approach that incorporates case management, parent education groups, and in-home family therapy sessions.

ACCOUNTABILITY

Accountability is an important component of change with all psychotherapy clients. Internal motivation often waxes and wanes, so an external motivation is often helpful in achieving positive change. This is a particularly difficult and important issue for marginalized and addicted clients. Such individuals often perceive an external locus of control, be it the court system, the desire for the drug or the high, etc. The SNIT as an intervention allows the family to be empowered by natural support in their environment. We refer to family, friends, and lay community support as natural supports, and we refer to professionals such as therapists, social workers, law enforcement, and probation officers as professional supports. This support system allows the clients to fully engage in their treatment. Over time, being engaged in treatment tends to move the locus of the client's motivation from external to internal. The structure of the team, in a real sense, facilitates this process. Individuals who have a stake in the client's participation in therapy and ultimately their success are included on the team. This allows the client's SNIT to be invested and available to intervene directly when issues arise. Galanter (1993) would speak of this process as coercion. We think of this process as shared accountability. By moving over time from shared accountability to self-motivation, clients are able to develop increased capacity for making their own good decisions. By empowering the family members to be more effective in their attempts to influence the addicts, greater and more potent assistance is given to aid in their recovery. Additionally, SNIT meetings provide a forum for the stakeholders involved in the client's treatment to speak directly about their expectations for the client. Such involvement has proven effective in reducing the amount and degree of splitting between client and SNIT members.

Splitting is a phenomenon that occurs through client manipulation when different stakeholders do not share a common conceptualization of the treatment plan. For example, in one case, a 19-year-old client denied emphatically that her family was involved in her life. Shortly thereafter, the client's older sister came to our office and reported that the client had recently been using inhalants. The sister reported based on information overheard by the client's mother. This revelation indicated that the family was in fact significantly involved in the client's life. The treatment team acted quickly to invite both the sister and mother to a SNIT meeting. Here they were recruited to be active members of the client's support network, thus disabling the negative splitting behavior.

Splitting most frequently occurs between the client and external directive entities, such as the Department of Social Services (DSS) workers, representatives of the court system, or when severe consequences could result from treatment failure. In such situations, the client will often negatively portray the different agencies as being “out to get them.” For example, it is common for clients to try to pit the therapist against a DSS worker by making statements such as the DSS worker wants to see the client fail so they can remove their children or other purposefully derogatory complaints.

STRENGTH BASED

The SNIT builds on the notion borrowed from solution-focused therapy (McCollum & Trepper, 2001) of strength-based intervention. From this perspective, little emphasis is placed on the origins of the current difficulty. Rather, emphasis is placed on supporting and expanding the aspects of one's life that are going well. As the client has success, they experience growth in self-esteem. This improvement in self-esteem feeds back into their ability to abstain from drugs and alcohol.

While the emphasis is placed on improving functioning in the present, it can be a clinical error to completely ignore the past. This is especially true early in treatment. One needs to have enough history to understand the context of the addiction and other problems in the client's overall functioning. Retrospective evaluation of problem formation can provide valuable information for solution generation. However, overemphasis on the cause of a problem can distract from the client's ability to find new solutions to their problem. Frequently, addicted families are so problem saturated that the focus is solely on areas of dysfunction, making it is easy to become bogged down in overwhelming complexity.

The strength-based perspective serves two key functions. First, it allows clients to be aware of positive experiences from which they can build experiences of competence. Second, it helps build a strong rapport with clients who often feel stigmatized due to their substance use and often criminal histories. This rapport is especially important for the court-referred or otherwise involuntary client to help establish a comfort level that will facilitate the movement from external to internal motivation.

COLLABORATIVE CULTURE

Addiction, by its very nature, is socially isolating, and the SNIT serves to assist the client in expanding their social network and in using available resources. This tribalization effect helps not only in using available community resources but in securing greater social capital with family and friends. Though seemingly counterintuitive, as support from others in the support network increases, ultimately improved bonds and attachment relationships between the system and the client effectively produces not only a safe environment but an overall sense of security which, as Johnson and Williams-Keeler confirmed (1998), leads to increased self-efficacy. Thus, self-efficacy is not reached through independence, but interdependence. Such interdependence strengthens the client's own locus of control and provides knowledge of available resources and assistance. This reduces service dependency, the need for long-term treatment, and recycling through the treatment system.

Approaching collaboration as a cultural issue helps the families collaboratively develop positive values and practices. By having the SNIT meetings focus on collaboration, natural support, and interdependency, we assist the families in moving away from self-destructive isolations and failed attempts at self-sufficiency. Also, a collaborative culture serves to provide a greater number of possible solutions as well as to provide feedback that may inhibit families from forming solutions that are inappropriate or ill conceived.

TRANSITION ASSISTANCE

A common symptom of the disorganization associated with addiction is that clients have difficulty with life transitions. By and large, our clients struggle with issues that are a direct result of their limited resources. Our clients often have to make transitions such as finding new housing and securing new, stable employment. The SNIT provides a forum where clients can seek assistance with these issues.

The process of the SNIT allows for creative solutions to emerge. Having participants in the SNIT who are connected to the client but removed enough from their day-to-day disorganization allows for new perspectives on transitional problems. Frequently, clients experience natural transitions as crises rather than being developmental. The SNIT can allow for such transitions to be contained and normalized rather than becoming a crisis.

PRAGMATIC ROLE OF THE SNIT

In addition to the therapeutic functions served by the SNIT, the meetings serve as an opportunity for the team to advise the family on more pragmatic issues. Obtaining adequate shelter, clothing, food, and transportation are frequently difficulties for substance-abusing clients. Likewise, issues regarding child custody and placement are often salient during such meetings. As Maslow (1943) has pointed out, basic needs must be met before higher needs can be focused on. For substance-abusing clients, before the more basic needs for the addict and their family members are met, the addict is unable to effectively and consistently focus on their abstinence and recovery.

Discussion of these needs when stakeholders are present allows greater creativity in developing unique solutions for the pragmatic issues the family faces. It also allows the SNIT to assign tasks to members of the group who are willing to work with the client in a more immediate and direct manner. For example, a client with a history of missing therapy appointments due to transportation issues might have a friend as part of the team who would be willing to transport him or her to therapy but was unaware of the problem. Such arrangements allow accountability from a member of the support system who is able to follow through.

ENABLING VERSUS SUPPORTING

In working with clients who are dealing with addiction issues, supporting the client without enabling them is an ongoing struggle. This is an inevitable process because of the dynamic nature of the boundary between enabling and supporting, as well as ever-changing contextual influences. As Jackson (personal communication, February 16, 2007) has stated, “The difference between enabling and supporting is like the difference between alcoholism and social drinking—you can tell you have crossed over when it does damage to yourself and your family.” Given this, it is apparent that the boundary between enabling and supporting can often only be discovered in retrospect, after having been crossed.

When providing such intense and proactive treatment, it is important to avoid enabling the client and the client's family by not doing for them what they could be doing for themselves. Initially, there is a greater amount of support provided by SNIT members to facilitate bringing the client to a point of greater self-efficacy. As the client and their family are able to begin taking greater responsibility for their needs, treatment providers should be able to adjust their methods to empower clients and encourage greater self-efficacy. If treatment fails to make the transition toward self-advocacy of the client and their family, the client risks becoming service dependent. When service dependency occurs, the tendency is for the professional providers to move toward burnout, and the natural supports to withdraw and/or emotionally disconnect from the family or addict.

Similarly, issues of codependency must be confronted on an ongoing basis. In some instances, it might be appropriate to address codependency as part of the SNIT meeting. However, codependent behaviors on the part of the professional caregivers should be discussed in staffing meetings or supervision out of the purview of the clients. This helps maintain professional boundaries as well as support therapeutic rapport. The best way to address codependency with clients is to confront them. This can occur during the SNIT meeting, as well as during ongoing therapy. It is important to challenge the client system to be self-reliant while confronting them on codependency issues.

TEAM COMPOSITION

The SNIT should be composed of all major stakeholders. Examples of such stakeholders could include immediate family, people residing in the home, supportive friends, social workers, school counselors, teachers, guardian ad litems, attorneys, probation officers, or anyone with a strong tie to the individual client or client family. The more stakeholders present for the SNIT meetings, the more effective they are in providing comprehensive support, reducing triangulation and coalitions, and generally increasing overall effectiveness of treatment and support.

It can be difficult, however, to identify stakeholders who should be involved in the SNIT. After a long history of substance abuse, clients often come to treatment describing cut-offs from family members and active relationships only with fellow users. In these cases, more proactive measures may be needed in assessing potential SNIT members, and/or treatment focus would center on developing positive relationships and supports.

Clinicians must understand that bringing in family and friends to a SNIT can be a difficult step for a client to take. Clients often feel extremely vulnerable at the thought of meeting with the SNIT team and can deny having supports to avoid involving them in treatment. Distinguishing between true isolation and a client claiming isolation to avoid the SNIT process can be a challenge. Processing these issues with the client, as well as talking to supports the client does identify, can help clarify other support that is available.

When a client is truly isolated, treatment providers, social workers, attorneys, probations officers, and other professional supports can be the only individuals involved in the SNIT. For clients who are not involved with any of these agencies, attendees can be even more limited. In this case, again, a major goal of treatment would be to build up the client's social support so that they would no longer be isolated.

Ideally, the SNIT should be composed of all major stakeholders. However, experience has taught us that some people are not appropriate to be members of a SNIT team. Examples include persons with significant history of being abusive or children who are not emotionally mature enough to tolerate the meeting. While the purpose of the SNIT is to be inclusive, it is important to control membership so that the meetings are safe and constructive. This is not only important for the success of the SNIT but models appropriate boundaries. Again, this becomes a starting point and creates a treatment goal of increasing positive supports, which may be in the form of rebuilding positive connections in the family or of building new connections outside the family.

Because there has often been a history of dishonesty and hurt in families we work with, there are often tensions present between members of the support team, even when family members are basically supportive. It is helpful to address this possibility at the beginning of the meeting and be clear about the “rules” (Figure 1). Framing the initial SNIT as a starting point, normalizing the presence of these issues, and acknowledging that many issues will not be addressed at this time can be helpful in setting expectations for the meeting. Also, we can let those present know that addressing such issues can be planned later on, during the treatment process.

FIGURE 1 SNIT Client Handout

During the meeting, the facilitator must cautiously guide the SNIT in the direction of responding to the questions presented (Figure 1) and must rein in the group should they stray far from the agenda. At times, this means strongly redirecting the group and reminding those present of the rules. Isomorphic processes from chaotic and diffuse family boundaries easily transfer to the SNIT. For the SNITs to be an ongoing, useful part of treatment, the initial SNIT must be experienced to some degree as supportive for the client. At the same time, it is quite clear that there may be some very difficult issues to be addressed. There is a specific question regarding a “concerns” agenda, though it is understood that all concerns may not be solved at this time. Keeping firm boundaries helps solidify the SNIT as a safe and supportive environment, making it therapeutically productive as well as a template for post-treatment family interaction.

This approach allows a balance of “positives” and “negatives.” Our experience is that creating a space to respond to the specific questions addressed in Figure 1 allows families to be in touch with the positive feelings they have for their family member, as well as their hopes and fears. In many families, it has been a long time since the addict has heard anything about what the family feels about their strengths, what they mean to the family, and what their sobriety means to their family. It has also often been a long time since the family has considered these thoughts. This can become an emotional experience for the family as they “remember” their caring for each other.

TEAM DEVELOPMENT

SNIT teams need to be set up as early as possible in treatment, beginning with the first encounter with the client. It is important to frame the SNIT as an integral rather than optional component of their treatment. It is also important that they not view the SNIT as a single one-time event, rather as an ongoing, key component of treatment. As mentioned before, clients often are reluctant to inform you of all stakeholders, and extra effort must be made by the treatment providers to ensure that the team is as comprehensive as possible. It is often helpful to begin building the team with the stakeholder who holds the greatest leverage over the client, be it a probation officer, a DSS worker, or a spouse requesting the treatment. Often, these people will be aware of many or most of the other stakeholders. As time progresses and circumstances change, it will often become apparent that more people should be involved on the team and should be included as soon as possible. Efforts should be made up front and throughout treatment to inform stakeholders of their important role in treatment and the need for their continuing participation.

An issue in this approach to treatment is the time it takes to set up the team meeting. We try to put as much of the responsibility for inviting team members on the client as possible, but this is often difficult at the beginning of treatment, when the client is often resistant to the idea of the SNIT. Though proactive SNIT formation clearly is time consuming for the treatment provider, the SNIT can often save time in the long run by having “everyone in the same room,” which helps avoid triangulation and confusion in the treatment process. This is especially true with respect to working with other agencies (DSS or probation in particular), where it helps to make sure everyone is on the same page and all requirements are being met. DSS, for example, may require parenting classes that we would not be aware of without meeting with them. Also, once initial SNIT members are recruited, they often become instrumental in recruiting other team members, thus removing some of the burden on the treatment provider.

Although we work to find times for the SNIT that work for everyone on the team (often in the evening), at times not everyone is available to attend team meetings. Our experience, however, is that despite being extremely busy and taxed, the agencies we work with all see the usefulness of such a meeting and try to attend. At times when they are not able to, we are glad to ask for their responses and any input over the phone, and the treatment provider presents that information at the meeting. (See the case example below for an example of this process).

The SNIT described in this article is the initial SNIT meeting, which ideally takes place during the first 10 days of treatment. The initial SNIT meeting is generally more structured than those that follow, and follows the specific format described below. Subsequent SNITs are called by the client, treatment provider, or other team member on an “as-needed” basis. These subsequent meetings are typically called when there is a crisis in the treatment (i.e., a relapse, a concern from the team about the possibility of a relapse, a difficult issue such as housing or transportation that the client needs help solving, etc.), at transition or progress points, or when the client has success in treatment such as graduating from the program.

A follow-up SNIT can be “called” by any member of the support team. In the initial SNIT, an agreement is gathered (and permission granted by the client) for anyone on the team to ask for a team meeting if they have concerns about the client. Family members often say they “know” when the client is heading in the direction of relapsing and respond positively to having the option of calling the treatment provider and asking for a team meeting should this happen. The treatment provider also asks permission from the client to call and check in with support team members if the treatment provider has any concerns. All members of the team are given the treatment provider's contact information.

At the start of the initial SNIT, a sheet is passed out which contains a reminder of the rules as well as a list of the questions to be covered. This sets an agenda as well as details appropriate behavior for the meeting (see Figure 1). During the meeting, one of the treatment providers completes the team meeting summary sheet. This serves to provide a framework for the process notes as well as a summary sheet that is mailed out to the stakeholders after the meeting (see Figure 2).

FIGURE 2 Team Meeting Summary

FORMAT OF THE SNIT

Although each SNIT has its own character and uniqueness, the general format of the meeting is as follows:

1. Approximate time:1 hour (varies depending on number of people present).

2. Minimum two treatment providers—one to run the meeting, one to take notes.

3. Team should sit in a circle or other nonhierarchical format.

4. Treatment providers should sit across from each other so they are able to make eye contact and support each other in managing the meeting.

5. The “rules” (see Figure 1) are handed to each person present, and each person writes their name and address on the sheet to be handed in at the end of the meeting.

6. The SNIT leader begins the meeting by welcoming those present and thanking them for coming. At this time, the overall goals of the team meeting (to support the client, make sure everyone is “on the same page” with treatment, and address some concerns) are presented.

7. The SNIT leader reviews rules and presents context for addressing concerns at the end of the meeting. Also, the SNIT leader emphasizes that all concerns will not be addressed and resolved in this meeting, normalizes families having many concerns and issues to address, and frames treatment (rather than the SNIT) as the most effective place to deal with those concerns in detail.

8. The SNIT leader asks for responses to questions from each person in the room, in rounds format. The assistant takes notes of responses.

9. The SNIT leader facilitates development of a crisis plan, including gaining agreement from all present to call a team meeting should there be a crisis, or if there are concerns.

10. The SNIT leader and team decide whether to plan another team meeting at this time or leave that open.

11. The SNIT leader thanks the team and closes the meeting.

To understand the process of the SNIT, we present here a case example. While this session was not recorded or transcribed, it is presented from the therapists' (Zimmerman & Dome) process notes. While this is not a verbatim report of the proceedings, it does capture the essence of that session and serves to illustrate the SNIT process.

CASE EXAMPLE

The following case example is taken from an actual SNIT. The names have been changed as well as other identifying information, but the general process and content of the original SNIT remains. Some commentary on the processes involved in the SNIT is provided to identify salient points.

Susan is a 34-year-old Caucasian woman who has been using primarily methamphetamine and marijuana for more than 10 years. She faces charges of methamphetamine manufacturing and is on intensive probation. She grew up in an intact, two-parent home. Her parents did not abuse substances. She has a close relationship with an older sister who lives about 30 minutes away, and works in the medical field. Although she described symptoms of depression, these symptoms became less prominent as Susan stabilized in her recovery. She was not prescribed any psychotropic medication.

Susan has a teenage daughter, May (age 16), who is currently in the custody of the DSS. The family is working toward Susan's abstinence from all drug usage and reunification of child and mother. There is a target date for reunification of 3 months from this support team meeting. At the time of this meeting, Susan had just returned from a 28-day inpatient substance abuse treatment program.

Susan is involved in an emotionally abusive relationship, with a man (John) who is also on probation for drug-related issues. She has been in this relationship (off and on) for about 3 years. She describes a history of abusive relationships and tends to see her current relationship as an improvement for her, because it is not physically abusive. Susan acknowledges her “bad choices” related to men and sees this relationship pattern, though she also continues to find reasons to stay in the relationship. She also tends to “blame” her own substance use (minimizing her own addiction) on the men in her life, by saying that she only uses because they are using. She acknowledges a fear of being alone.

Susan continues to struggle with deciding how to proceed regarding this relationship. Before going to treatment, she had decided that on her return, she would live with her mother, rather than return to living with John. John regularly uses marijuana, though he says he is willing to stop to support her recovery. She acknowledges that there has been ongoing emotional abuse throughout their relationship, and she has not seen evidence of him taking any steps toward stopping drug use.

When she returned from inpatient treatment, Susan reported feeling strong and positive about her recovery. The therapists described the SNIT to her as an opportunity to gather the people in her life who are supportive, with the purpose of including them in her recovery and getting everyone “on the same page.” Susan was actively involved in deciding who to invite to the meeting. Susan and her therapists decided to invite the following: representatives from the agencies involved with her family (DSS, probation, her attorney), her daughter, and her parents. Susan also decided to invite her daughter's foster mother, another close friend, and the county sheriff.

Prior to this meeting, Susan distributed invitations to each person she wanted to invite to the SNIT. She was extremely conscientious about getting the invitations signed by each individual and returning them to her therapist, Joan Zimmerman. This process seemed to help her feel both proud of the progress she had made and empowered.

On the day of the meeting, neither her close friend nor her probation officer could attend. Rather than rescheduling, Susan's primary therapist decided to receive input from the probation officer over the phone to be presented at the SNIT meeting on his behalf. He reported that Susan had informed him that she made the decision to move back in with her ex-boyfriend, John, rather than follow through with her plan to live with her mother. He requested that Susan be informed about his strong concern regarding this decision. He also wanted to be sure that Susan understood that if she was in John's house and illicit substances were found in the house, Susan would be held responsible as well and would be charged with a probation violation. The probation officer also informed us that on the morning prior to this meeting, Susan was served with a two-count indictment from prior methamphetamine-related illegal activities.

The following people attended Susan's SNIT meeting: Susan's daughter, Susan's mother, Susan's father, the county sheriff, Susan's daughter's foster mother, the family's DSS worker, Joan Zimmerman, family therapist, and Susan's individual therapist, and Lance Dome, family therapist.

A general introduction was made, giving those present a brief overview of the treatment program and purpose of the SNIT and introducing the therapists to the stakeholders present. At this time, the SNIT meeting rules were reviewed. The basic rules are as follows: 1) Remember, children are listening; 2) respect and courtesy at all times; 3) no put downs or blaming. If needed, additional rules can be made by the group. In this case, however, the standard rules sufficed.

During the meeting, the following topics/questions are addressed:

1. How are you involved with this person (family)?

2. What are some of this person's (family's) strengths?

3. What supports are you currently giving?

4. Are there any other supports you could offer?

5. Requirements of DSS/law enforcement.

6. Treatment plan, including crisis plan.

The following questions were posed during this meeting, followed by the responses.

How Are You Involved with Susan and Her Family?

This question serves to open the session and allows all parties to make statements about their level of involvement with the client. While some choose simply to identify themselves, often participants make encouraging statements toward the client at this time. This session started with Susan.

Susan: said that she was glad to be here and was thankful for all who were present. Susan also apologized for the past and stated she knows she cannot change the past, but can start from here.

Susan's daughter: She introduced herself. (At this point rather than pressure her, the therapist decided to simply let that simple statement stand.)

Susan's Mother: “I'm seeing a side of Susan I've never seen before. Her head is clear. She is fun.” Her mother also expressed gratitude for the emotional and cognitive return of her daughter.

Susan's Father: He introduced himself. (Again the therapist allowed his interaction to stand with a simple introduction.)

County Sheriff: (He has known Susan for many years.) “I'm honored to be here.” (This was an emotionally powerful statement and served to provide a good deal of support to Susan in her recovery.)

Foster Mother: She introduced herself.

DSS: The DSS worker introduced herself and reminded the group that currently DSS has legal custody of Susan's daughter. This served to focus the group on the goal of Susan regaining custody of her daughter.

Joan Zimmerman: She introduced herself as a family therapist with the methamphetamine program, who works individually with Susan.

Lance Dome: He introduced himself as a family therapist with the treatment program, who also works with Susan.

Commentary. During this portion of the session, emotions were expressed powerfully. Several participants were tearful, and the sheriff had watery eyes. These were not tears of shame and sadness but rather tears of hope and loving support. There was also much hope for the future expressed, and a vision of the possibility of Susan taking a direction very different from the past.

What Are Some of Susan's Strengths?

Joan Zimmerman: shared how impressed she was with Susan's willingness to change many aspects of her life. Not only was she impressed by Susan's changes but in her willingness to call for help from others in her life. In addition, Susan had displayed a positive attitude toward her potential future, and in particular, she has had a positive attitude toward law enforcement and DSS. She also was encouraged that Susan did not see these authorities as adversarial but as powerful agents of change in her life.

Lance Dome: was impressed that, despite her severe problems with addiction, Susan remains a caring person toward others. She loves her daughter and is motivated to stay involved in her life and regain custody.

Foster Mother: was struck by Susan's love for her daughter. She reported that Susan constantly checks up on her and is concerned with how she is doing.

Susan's Daughter: simply stated that she thought her mother had the strength to do what she wants to do.

Susan's Mother: stated that Susan makes the good better. She moves on, away from the past and has a focus on the future.

Susan's Daughter: jumped back in and stated her mother has the strength to go on, no matter how far down she is. Susan has already realized she has a problem. She saw admitting a problem as the hardest part. She is optimistic that Susan can build from here.

Susan: felt that her daughter was her biggest strength. It was she that motivated her to go on with her treatment. Caring for an elderly patient has given her strength. She also expressed that being in touch with her higher power is a source of strength. This indicates that she has integrated aspects of the 12-step process into other areas of her life.

County Sheriff: was impressed by the strength of Susan's personality. He stated that despite the nature of their relationship that “to know her is to like her.” He was also impressed by her strength to admit she has made mistakes and the willingness to do what it takes to repair the damage she has done in her life with her addiction.

Commentary. During this portion of the meeting, the positive attitude in the group continued and became even more profound. The participants discussed and highlighted Susan's strengths as attributes that would be necessary for her success. Also striking in this section is a strong, three-way sense of connection between Susan and her mother and daughter—and how the positive feelings persisted despite the real legal jeopardy Susan was facing.

What Does Susan's Sobriety Mean to You? How Would It Impact Your Life?

Foster Mother: wanted Susan and her daughter to be happy and back together. This will allow them to begin a normal mother/daughter relationship.

Susan's Mother: was most concerned with Susan's ability to be honest. She stated that she hoped Susan can be up front and clean. Her mother saw this as the first step in a process of rebuilding trust.

Susan's Daughter: was brief but global in her statements, stating that Susan's sobriety “means everything.” She agreed with Susan's mother that her mother's sobriety was the first step toward them being able to have normal family relations.

Susan: was glad that her family relationships could become more normal. She stated that her daughter “won't have to play ‘little mom’ anymore.” This indicated awareness that her daughter had been over-functioning to try to make up for her addiction. She stated that being able to function as a parent to her child will be positive for her self-esteem. She made the statement that, “I can love myself too.”

County Sheriff: saw the meaning of Susan's sobriety as hope. It allows him to see that people can beat methamphetamine addiction and that they can change. Regarding Susan in particular, this means to the Sheriff that she is strong and willing to change.

DSS: was glad to see the possibility of the family getting back together. They were optimistic that in the future the family could be permanently reunited and that they could close the case.

Commentary. This part of the SNIT frames the course of the treatment. It allows each person to attempt to provide motivation for the client. This portion of the team meeting was emotional and personal. It is our experience that toward the beginning of therapy, clients tend to be externally motivated by family members and public agencies such as the legal system or DSS—motivation tends to be external. In this interview, the locus of motivation is already shifting. While the public agencies provide motivation, we see the client and her supports as starting to own their own motivation. As motivation moves from external to internal, change and recovery become increasingly stable.

This portion of the session also served to build upon the relationship between the three generations of women in this family. There is a direct call for a return to “normal” familial relations by all three women. This helps further focus the positive framework of this treatment and sets the future agenda for family sessions to focus on returning the family relations to a more functional and structurally appropriate state. In this family, that would mean Susan being successful in the role as mother, allowing her daughter to be a child and her mother to be a grandmother.

What Supports Are You Giving Currently?

Because this is a more direct and closed-response question, the responses were succinct.

Foster Mother: stated her support was primarily caring for Susan's daughter and being “there” for them.

Susan's Daughter: stated she will support Susan “in any way I can.”

Susan's Mother: said, “I'll always be there for any support she needs.”

Susan's Father: said, “I'm there whenever she needs me.” He stated that he tries to be open with Susan and doesn't “sugarcoat things.”

County Sheriff: said, “I'm here today,” and “I'm a phone call away.”

DSS—stated that she had outlined what Susan needs to do and will monitor updates on how she is doing.

Commentary. In this portion of the SNIT, there is a shift away from a focus on emotional issues to more pragmatic ones. Here the participants discuss what supports they are providing to the client. This can also provide an opportunity to address supports that are needed but are not currently being provided. It is during this portion of the session that the representatives from the DSS outline their involvement. They lay out their conditions and expectations for custody of the child to be returned to the parent.

Are There Any Other Supports You Could Offer?

Susan's Mother: said, “If she begins to slip, I will bring it to her attention.”

(There was also some discussion of the importance of bringing “slips,” problems, etc. to the attention of the rest of the support team, rather than just Susan, and to effectively use the support that is available from the team.)

Susan's Daughter: felt like her mother's boyfriend could offer more support.

Susan: said, “You are all the greatest support I could have.” She also talked about needing a vehicle for transportation and possibly some help with housing. She says she feels like she is coping well and will ask for help as she needs it.

Commentary. This portion of the SNIT continues the pragmatic focus of the session. A shift occurs from current focus to future focus. This allows the team to assist in providing the client with additional supports. Issues like child care, obtaining shelter, and transportation can be addressed during this time. In addition, Susan is becoming empowered during this portion of the interview. She is able to further state that in the future she will be able to ask others for support when she becomes overwhelmed.

Do You Have Concerns?

At this point in the SNIT, the focus shifts from support to collaboration. The parties involved are asked to raise any concerns and find acceptable responses to relapse or other significant concerns. The team is aware that Susan is thinking about living with her boyfriend again. In the past, he has not been supportive of her recovery, and he himself uses marijuana. Each member confronted Susan on the following.

Susan's Daughter: again expressed concern about Susan's boyfriend, that he is not being supportive enough.

County Sheriff: stated concern that Susan's continued involvement with her boyfriend meant that she had some more issues to address.

DSS: shared that she thought it was smart when Susan left her boyfriend. However, she was surprised that Susan is back with him and is concerned for Susan's and the child's safety.

Foster Mother: shared that she had the same concerns as the others regarding Susan's boyfriend.

Joan Zimmerman: quoted Susan's probation officer, who stated, “If there are drugs in that house, Susan is a part of it. If he goes down, she will go down with him.” (This served as a strong confrontation of Susan's potentially destructive relationship.)

Commentary. Ideally, the probation officer would be present in the session. However, the urgency of the situation dictated that the session was held despite the inability of the officer to attend. To increase the impact of the gravity of the situation, Joan Zimmerman read a direct quote from the probation officer. This encouraged Susan to address this issue.

Susan was able to hear the concerns voiced as genuine concerns, rather than “attacks.” Because of the timing of this section of the SNIT, a strong, supportive atmosphere had already been created in the room. If these concerns had been presented earlier in the session, Susan may not have been able to respond without becoming defensive. At this time, however, Susan was able to genuinely consider the concerns presented, and in fact, she decided that restarting her relationship was not a good idea. She became tearful and said that she had not realized the possible consequences of this decision. Susan decided to return to her original housing plan and requested that she be allowed to return to her mother's house to live. It was apparent that she gained some further insight into the impact that her relationship with her boyfriend had on those around her.

This is an example of a time when the SNIT blocks triangulation of the various individuals and agencies involved in treatment. At the time of the SNIT, Susan had not acknowledged her intention to move in with John to her treatment providers and had only suggested the idea to her family. The fact that the issue was raised by the probation officer made it impossible for Susan to gloss over this decision. The concern expressed by the probation officer also served to help the family express their own concerns clearly, making a strong coalition among the team. This situation also emphasizes the importance of the treatment team being proactive in recruiting the team and gathering verbal input if the team member cannot actually be present.

It is important to note again the importance of the supportive atmosphere of the SNIT. One of the responsibilities of the leader of the SNIT is to monitor the atmosphere of the session and keep control of the amount of tension in the room. How concerns are addressed will be very different with each family. It was clear during Susan's SNIT that she felt she had support from her family, and openly addressing concerns and issues was appropriate and helpful. In other cases, it may take more time for such processing to be productive, and the treatment provider may remind the team of the original point that all issues will not be resolved in this meeting. One of the most challenging parts of leading a SNIT is helping the team find a productive balance between supporting the client and addressing very real, emotionally charged concerns and issues.

Requirements of Social Services/Law Enforcement

In this part of the SNIT, the therapists and the other professional supports work as a team to make sure the client is aware of any pragmatic/legal/DSS issues. The timing of Susan's SNIT coincided with an ongoing legal issue that was scheduled to be adjudicated. Earlier that day, she was served by the sheriff with legal papers. Prior to this session, the therapists were using the knowledge that these charges were coming to provide motivation for the client. This example highlights how this model uses crisis situations as opportunities for change and sees such matters as appropriate to address in the SNIT meeting.

In this portion of the intervention, the focus shifted when Susan's motivation to make a good choice about her boyfriend moved from external to internal. This occurred when the probation officer's comments regarding her boyfriend were presented. Here she became emotional and began to put her needs for sobriety and her daughter's needs for an involved mother as a higher priority than her needs for intimacy with her partner. Now that Susan has become more self-motivating and reached what the team thinks is an important decision, the professional supports quickly reinforce this decision. Each professional speaks about how this decision will improve her ability to meet her goal of sobriety.

County Sheriff: in talking about her legal issues, he stated that he would have no problem describing positive changes he has seen in Susan.

Joan Zimmerman: showed support saying she could write a letter stating Susan is in treatment and is compliant with the treatment program.

Treatment Plan and Crisis Plan

In general, each SNIT is concluded by referring to the client's treatment plan for updating as needed and to make those present aware of the client's goals. In addition, a crisis plan is addressed, and a commitment from the team (including Susan) is gathered to call a team meeting if a crisis occurs or if anyone has concerns (for example, of relapse).

In this particular case, there were two goals. The first was abstinence from all drugs. In this SNIT, Susan's progress toward this goal was affirmed and enhanced by her reaching a decision not to live with her drug-abusing boyfriend. As this decision was reached, there was a shift in the locus of the client's motivation (from external to internal). The second goal is improved family functioning and reunification of the family. Here, Susan put her relationship with her daughter and parents above her relationship with her boyfriend and drugs, taking a step toward improving the family structure by taking on the role of a parent.

The team agreed that a relapse would be a crisis for Susan. They also agreed that Susan reuniting with John would be a crisis. The team made a plan to call Joan Zimmerman, the primary therapist, to schedule a SNIT if they had concerns that either of these two events had occurred or appeared likely to occur. Susan gave permission, and actually encouraged those present, to do so. Susan also agreed to talk to her family and treatment providers before changing her decision regarding her relationship with John and also if she felt at risk of using.

What Happened?

This meeting was a powerful experience for all those in attendance. Everyone in the room was touched by Susan's courage and her ability to face and deal with difficult issues. The team was also struck by her close relationship with her daughter and by her daughter's ability to be forthright. The team's acknowledgement of how hard Susan has worked and how far she has come seemed to have a positive effect on Susan and facilitated her movement toward self-efficacy. She became tearful several times during the meeting as she heard the care and support that was expressed by those in the room with her.

She was also willing to hear criticism, evaluate it, and incorporate it. This was demonstrated as her supports confronted her decision to move in with her boyfriend. By the end of the meeting, because of insight gained from the concerns raised, she decided to postpone moving back in with him. She stated that the words of her probation officer hit her particularly hard. She realized the risk she would be assuming with respect to her own sobriety and legal situation, as well as the risk to the possibility of reuniting with her daughter. During the meeting, she arranged to have her mother drive her to her mother's house that afternoon. Those present reminded her that her boyfriend is welcome to join her in the treatment program, and his doing so would be a sign that he is willing to consider making some positive changes.

By the end of the meeting, the feeling in the room was that a cohesive team had been developed and that Susan was certainly not fighting her battle alone. Each group within the SNIT (DSS, probation, mental health, substance abuse treatment, Susan's friends and family) had initially been working individually with Susan, but this meeting was the first time they all met together. Thus, a stronger, more cohesive support network was created. While this particular SNIT departed from the usual development of being called at the start of treatment, it was successful in unifying the natural and professional supports in their support for this client.

Follow-Up

Susan continued to be successful and involved in treatment until she “graduated” successfully from the program. During that time, she regained custody of her daughter. She had a final SNIT when she graduated, which all those involved in the meeting described in this article attended, as well as her sister. Susan continued to struggle with relationship issues, though seemed better able to set clean boundaries. She was able to stay clean and sober. Since her graduation, Susan has stopped in each year at Christmas to check in with treatment providers. She says that she knows we are thinking of her and wants us to know that she is doing well.

CONCLUSION

The SNIT is both an intervention and a modality of a systemic approach to substance abuse treatment. It is an intervention in that it helps unify support and create accountability. Part of this accountability means clients realizing that their addiction not only affects them but also their family. When a stakeholder recognizes and shares what the client's sobriety means to them, it changes the context of the addiction for the addict. It facilitates the client's move from egocentric to communal awareness. The SNIT builds on the strengths of the client and of the family. This is paramount in changing the focus of treatment from being solely on the addiction and related problems, to building on strengths and increasing capacity for innovation. The SNIT draws together all of the client's supports, both natural and professional, and helps create a collaborative culture. This modality sets a forum where problems can be addressed collectively and efficiently. The SNIT as a modality allows the client to receive support while addressing issues of enabling and triangulation and, at the same time, creating greater opportunity for family buy-in and ultimately more effective and lasting treatment results.

The authors would like to thank the Reich College of Education at Appalachian State University for supporting the first author participation in this project and Keith B. Freeman for his editorial assistance with this article.