Application of the Brief Strategic Therapy Model to the Treatment of Drug Addiction

1. International Congress of Brief, Strategic & Systemic Therapists San Diego, CA – September 12 & 13, 2008 Application of the Brief Strategic Therapy Model to the Treatment of Drug Addiction Christian Moretto, LMSW, MBST Family Therapist, ASAS/WMMG Director of Strategic Therapy & Interventions of NY http://www.strategic-therapyandinterventions.com

2. Part 1: The Place & The Study OutpatientAlcohol and Substance Abuse Services • outpatient treatment facility • 1 Supervisor, • 1 Intake Coordinator, • 1 Psychiatrist, • 1 Vocational Specialist, • 1 Buprenorphine Treatment Specialist, • 3 Addiction Specialists (CASAC - Certified Alcohol and Substance Abuse Counselor) • 1 Family Therapist.

3. Part 1: The Place & The Study All the clinical interventions have been made following the Brief Strategic Therapy model and protocols developed by Giorgio Nardone in Arezzo – Italy. The Study: A snapshot of strategic interventions done on patients presenting with chronic drug abuse and dependence and all associated disorders and life problems. • 74 patients (40 males and 34 females) with 6 dropouts. • Chronic users (generally more than 10 years) • From October 2005 to July 2008 • Not a controlled study: 30 patients are still in treatment • and 44 have been discharged over the years.

4. Part 1: The Place & The Study “Life” Problems at Intake

5. Part 1: The Place & The Study Mental Health Cluster

6. Part 1: The Place & The Study Mental Health Cluster Patients were treated in collaboration with the unit Psychiatrist in order to: • Stabilize medication regimen. • Refer patients to outpatient mental health program. In case of referral to Outpatient Mental Health Program: • Patient presented with poor adherence to outside program. • Programs showed poor interest in dealing with these patients. • Most of the time, patients ended being treated by Psychiatrist and family therapist.

7. Part 1: The Place & The Study Substances Abused at intake

8. Part 1: The Place & The Study Substances Abused The 3 main areas of dependence and abuse are: • alcohol, • cocaine, • and benzodiazepine (Xanax, klonopin, valium, etc…). • Many methadone clinics in NYC are not accepting patients who are treated with benzodiazepine medication for a co-occurring mental health disorder. • Collaboration with psychiatrists and physicians (when possible and allowed by patient) is of primary importance.

9. Part 1: The Place & The Study Profile of an average patient

10. Part 1: The Place & The Study Profile of an Average Patient These data show the trees but not the forest: • Poor relationship with themselves, others and the world, • Poor communication skills, • Poor life experiences and ability to communicate outside of the drug culture (“the street”).

11. Part 2: The Results Criteria a- “Life” Problems: The 10 clusters: Family, couple, sexual, housing, income, work/education, legal, ACS, Health, Mental Health. • Major Improvement: >60% of “life” problems are solved Among the problems observed at intake or during treatment more than 60% are solved or very close of being solved (patient in training, family reunification pending a scheduled move to an apartment, patient accepted in a housing program depending on availability, etc…). • Partial Improvement: 60%>Problems solved>30% Among the problems observed at intake or during treatment more than 30% but less than 60% are solved. • Treatment Failure or No Significant Improvement: Problems solved<30% Among the problems observed at intake or during treatment less than 30% are solved or in process of being solved.

12. Part 2: The Results Treatment of “Life” Problems: Basic results

13. Part 2: The Results Treatment of “Life” Problems: Basic results • During treatment, 75% of the patients have experienced a Major or a Partial Improvement of their “life” problems (the10 clusters)

14. Part 2: The Results Criteria b- Drug addiction • Major Improvement: Drug consumption is reduced by >60% Using the patients’ consumption report at intake or toxicology screens before admission to ASAS (baseline), there is no consumption of drugs or consumption is reduced by more than 60% in a period of 3 consecutive months as shown by weekly toxicology screens and patient reports. • Partial Improvement: Drug consumption is reduced by more than 30% but less than 60% Consumption during treatment is reduced by more than 30% but less than 60% on 3 consecutive months as shown by weekly toxicology screens and patient reports. • Drug Treatment failure or No Significant Improvement: Drug consumption is reduced by less than 30% Consumption during treatment is reduced by less than 30% in 3 consecutive months as shown by weekly toxicology screens and patient reports.

15. Part 2: The Results Drug Treatment: Basic results

16. Part 2: The Results Drug Treatment: Basic results • There is no balance in drug addiction treatment: it’s all good or all bad. • These patients have Manichean behaviors and treatment outcomes are also Manichean. • 66% of the patients experienced a major or a partial improvement regarding their consumption of drugs.

17. Part 2: The Results Combination of treatment outcomes on "Life" Problems and Drug Consumption

18. Part 2: The Results Combination of the treatment outcomes on "Life" Problems and Drug Consumption An intuitive and apparently obvious result starts to emerge: 1-there is no “life” improvement with drug consumption ; or 2-there is no change in drug consumption without “life” improvement”. Which one comes first? Lets explore in more detail the 2 extremes of this graph: 1- Patients with major improvements in both their “life” problems and their drug consumption. 2- Patients with no significant changes in both areas.

19. Part 2: The Results Among the 54% with successful Drug treatment (N=37)

20. Part 2: The Results Among the 54% successful Drug treatment (N=37) Total Abstinence • If patients were able to maintain a balance consumption of drugs they would not have experienced the need to come to treatment. • As Saint Thomas Aquinas wrote “Complete abstinence is easier than perfect moderation”. Episodic Consumption • The rate of improvement of “life” problems is only half that of those who are completely abstinent. • Even consuming drugs in an episodic and moderate way has a significant negative impact on life (for these patients who are chronic users).

21. Part 2: The Results Among the 34% having No Significant Improvement in Drug Consumption (N=23)

22. Part 2: The Results Among the 34% having a No Significant Improvement in Drug Consumption (N=23) • The impact of drug consumption on life is the same for the two populations (minimal change and no change in drug consumption). In conclusion, • drug addicts treated in this program (chronic users) are incapable of moderation They are the champions of playing at the seesaw (vicious circle) in a frenetic way by : • escaping life problems through drugs; • and worsening their life problems by using drugs which will lead them to even more consistent or important drug consumption.

23. Part 2: The Results Conclusions: The two extremities of the spectrum are functioning in an dissymmetrical way: At the beginning of therapy • If one is only reducing his drug consumption a little bit, one will not experience significant changes in his life as compared to one who is using drugs as usual. • To prime the pump of change in these patients (chronic users) a significant effort needs to be made at the beginning of the therapy. Towards abstinence: • Even if one is consuming drugs sporadically, one will not experiencing the full effects on life improvement. • Total abstinence is key for this population (they are not capable of moderation)

24. Part 2: The Results Why drug addiction treatment is so difficult and ingrate to treat ? • Maximum efforts are required at the beginnings and yet is not immediately rewarding, • These efforts need to be pursued until complete abstinence is obtained in order to experience full life improvement. • If the efforts are not pursued until the end, chances of coming back to the starting point are not negligible. What comes first? “life” problems or drug addiction? This question ismeaninglessas: • they come together and fill each other at one point of the journey, • both of them are to be addressed during treatment in a kind of healthy and balance seesaw game, and • following a personal observation: patients have no problem when they are using drugs, during that moment everything is all right, it’s when they come back to life that problems resume… • Therefore, it would be a mistake treating only one aspect (drug) at a time.

25. Part 3: Perceptive Reactive System & Attempted Solutions Life’s Basic principle: keep a smooth balance

26. Part 3: Perceptive Reactive System & Attempted Solutions What are the problems generally presented by patients? 1- Others: • partner, family members, the kids, the therapists, probation officers, police, society… and 2- The world, the way it should be: • providing them instantaneous and effortless rewards and goods. • They are living in Utopia. 3- Themselves: • The way they should be. Based on my clinical experience, the problems are: • consumption of drugs, • the 10 clusters in the “life” Problems area, • lack of communication skills and ability to relate to others and the world in a flexible, civil and strategic way, • inability to delay rewards and to look for consequences, • lack of problem solving skills, • their illusions on self, others and the world,

27. Part 3: Perceptive Reactive System & Attempted Solutions Perceptive-Reactive System (PRS): The Lost Paradise and its 3 Myths Once upon a time we all were super humans and we were living in a perfect world (the lost paradise) • Self, others and the world should be different, They share with the Moralist (Muriana, Pettino and Verbitz): • paranoiac ideations, aggressiveness, anger, • resentment, unending grieving, • inability to compromise because of their rigid belief system, • Practical renouncement, • Fight using their mind but not concrete actions. The main difference with the Moralist : • They don’t renounce to their Utopia, they simply have found other ways. • Drug users’ perceptive-reactive system is based on the myth of a lost paradise.

28. Part 3: Perceptive Reactive System & Attempted Solutions PRS - The first myth: Spiderman or “I need a boost (the sting of a radioactive spider) to do the impossible • They are using all kind of stimulants (cocaine, crack cocaine, amphetamine, etc – around 35% of the cases) • They are missing the lost paradise where they all were once humans with super powers. • They have the tendency to focus on what they should be, how they should be, how things should be easy for them to do, • Logic of belief (there is something that will give me the strength) and paradox (control over a substance)

29. Part 3: Perceptive Reactive System & Attempted Solutions PRS - The first myth: Spiderman or “I need a boost (the sting of a radioactive spider) to do the impossible • Like Spiderman, they are able to do what seems impossible to them (with a little help) but back on earth… • they perceive themselves as clumsy, and socially inadequate with the opposite sex, friends, school, work, family, etc... • Like Spiderman, the more they retreat (forwards!) in their artificial ability to jump from one skyscraper to another, the more, when they are running out of gas, their fall is vertiginous and the resulting depression is proportional to the heights they were able to reach.

30. Part 3: Perceptive Reactive System & Attempted Solutions PRS - The first myth: Spiderman or “I need a boost (the sting of a radioactive spider) to do the impossible”

31. Part 3: Perceptive Reactive System & Attempted Solutions PRS - The second myth: Gollum or “let me enjoy “my Precious” alone in my cave as the world is a nasty place.” • These patients (about 30% of the cases) want to retreat from the world as the world and others are not the way they should be. • They are abusing depressants (heroin, alcohol, benzodiazepine, etc…) to be able to live in a cave and enjoy their “precious” utopia. • They all share the tendency to put the blame on their partners, the family, the society, genetics, laws - but rarely on themselves. • Very close to the Moralists in the Depression Area

32. Part 3: Perceptive Reactive System & Attempted Solutions PRS - The second myth: Gollum or “let me enjoy “my Precious” alone in my cave as the world is a nasty place.” • In the same way than the ring of power for Gollum, heroin consumption causes very deep physical and neurological changes (these changes are less important and less definitive with cocaine consumption). • Following the same path than Gollum, the more they retreat (forwards!) in their cave to enjoy the idealistic power of the precious, the more others and the world seem far away from their ideal and the more they will retreat. • Logic of contradiction (“the more I retreat the more I feel safe” – In fact, the more they retreat, the harder it becomes to deal with others and the world.), and logic of belief (“I can live in isolation”)

33. Part 3: Perceptive Reactive System & Attempted Solutions PRS - The second myth: Gollum or “let me enjoy “my Precious” alone as the world is a nasty place”

34. Part 3: Perceptive Reactive System & Attempted Solutions PRS - the third myth: The Sorcerer Apprentice or “I want everything and its opposite and without any effort” • These patients use cocaine in order to get the boost. • Then, they use heroine or any depressant to come down and to become more mellow (Approximately 35% of the cases). • Like the sorcerer apprentice (Fantasia – Walt Disney) they look for the easy way to do all the chores and be at the top without making too much of an effort (stimulant) and, • the quietness and comfort of a retreat from the world (with some depressant) where they can dream of infinite power over the elements and the world.

35. Part 3: Perceptive Reactive System & Attempted Solutions PRS - the third myth: The Sorcerer Apprentice or “I want everything and its opposite and without any effort” • Like the sorcerer apprentice, they nurture the illusion that they can master this explosive cocktail without needing to experience the path that lead from apprenticeship to mastery. • They forgot that Leonardo Da Vinci before being the greatest master of his Arts was the most modest servant of Verrocchio. • Logic of paradox (“control over myself and the substance that I put in myself”) and belief (“a magical product can give me the power over the elements and myself and I can be the best without efforts”)

36. Part 3: Perceptive Reactive System & Attempted Solutions PRS - the third myth: The Sorcerer Apprentice or “I want everything and its opposite and without any effort”

37. Part 3: Perceptive Reactive System & Attempted Solutions The attempted solution: “la fuite en avant” or “the retreat forwards” The vast majority of drug users are not developing dependence and addiction. • Gene Heyman, Research Psychologist at the Harvard Medical School: “between 60 and 80 percent of people who meet criteria for addiction in their 20s are no longer heavy, problem users in their 30s”. Are they different because of genetic weaknesses or natural predisposition? • Factors like family history, age of first use, impulsivity ability to handle frustration, and may be genetics may contribute to how one will end when starting using drugs. • But one will not develop addiction if one would not find any advantage or relief from it, • And if one would not experience problems perceived as unbearable when sober.

38. Part 3: Perceptive Reactive System & Attempted Solutions The attempted solution: “la fuite en avant” or “the retreat forwards” Drug consumption is the attempted solution that is maintaining their illusions: • of controlover one’s life, energy and capabilities (Spiderman: the boost = belief and paradox), • of being able to isolate from the world and others (Gollum: “I can be alone in my cave” = contradiction and belief) • of controlover self, others, and the world (Sorcerer Apprentice: the control over internal states, capabilities, an alchemic mixture, and the external reality = belief and paradox), Drug consumption is the attempted solution that is maintaining all life problems. • It would be a mistake to try to block the attempted solution without working on the “life” problems.

39. Part 3: Perceptive Reactive System & Attempted Solutions The attempted solution: “la fuite en avant” or “the retreat forwards” You would like to attain faith and do not know the way; you would like to cure yourself of unbelief and ask the remedy for it. Learn of those who have been bound like you, and who now stake all their possessions. These are people who know the way which you would follow, and who are cured of an ill of which you would be cured. Follow the way by which they began; by acting as if they believed, taking the holy water, having masses said, etc. Blaise Pascal, pensées 233 Addiction building follows the same path but in an opposite and unhealthy direction. The behaviors are creating and maintaining the negative illusions and the problems.

40. Part 4: Stratagems, Communication and Protocols The Stratagems The stratagems used with drugs addict will aim to: • Decrease their symmetrical interaction with themselves, others and the world, or increase their interactions with others and the world in order to decrease their illusion about self, others and the world. • Reframe their belief system with direct experiences. • Have them become more active, be in the doing rather than the dreaming, expecting, complaining. • Increase their problem solving capabilities. • Have them reduce their drug consumption (detox/rehab if necessary). • Have them being able to interact decently with others, • This task cannot be done in isolation (which would be the same solution that the patients are already applying).

41. Part 4: Stratagems, Communication and Protocols Stratagem1: Circular versus linear, linear versus circular • “Circular versus linear, linear versus circular” is the fundamental stratagem used with this population. • At the communicational and relation level, addict patients are very linear, they communicate and act symmetrically. At a communication and relational level: • By taking the complementary position of the patient, • by taking a complementary stance to what the patient was expecting of you at that particular moment. • It’s the equivalent of a reframing as it goes against their rigid perception and surprises him. • Irony and humor.

42. Part 4: Stratagems, Communication and Protocols Stratagem 1: Circular versus linear, linear versus circular When Patients were able to immediately admit their problem with drug and expect me to confirm their struggle: • “Please, do not try anything as we are all powerless in regards to addiction following the precept of AA: “We admitted we were powerless over alcohol - that our lives had become unmanageable” and we should be rather careful before changing anything after so many years of unsuccessful attempts. For patients that are unable to collaborate because intoxicated and therefore who have their head under the carpet: • Having as many people as possible intervene in the present situation After the crisis (circularagainst linear): • With “lying by saying the truth” and playing the naïve : “I thought you were sick and close to die” (which is partially true).

43. Part 4: Stratagems, Communication and Protocols Stratagem 2: “Lying by saying the truth” This stratagem comes in association with “Circular versus linear, linear versus circular”. • When humor and irony is used: “I’m joking…”, “I’m kidding…” “it’s not true” or by laughing loud to make them understand that it’s a joke. • “I thought you were dying..” • When a patient explain that he likes his life: “you’re right, and I don’t want you to change your life because …. Then you can trust me, I will avoid to turn you into a yuppie.” • Lying by saying the truth is used to intervene on the patient’s premises or on what he is expecting or believing from the situation or from others.

44. Part 4: Stratagems, Communication and Protocols Stratagem 3: “To catch something, first let it go” or “leaving later to arrive earlier” • As seen with other pathologies, we need to work on what is the patient’s problems when he presents it. • If the patient does not present drugs as being an issue… • It’s better always to avoid: “you only need to stop using”. • It’s very important to let patients make the first move and the first step like in the chess game… • Using strategic dialogue technique we base our progressions on patient’s assumptions and premises and we thereafter make him perceive his reality with a different perspective.

45. Part 4: Stratagems, Communication and Protocols Stratagem 4: “to plough the sea unknown to the skies” or “Deceive the heavens to cross the ocean” Or “let’s manipulate the manipulator”. At a communication level this stratagem is used through the systematic use of: • metaphors, • aphorisms, • story telling,

46. Part 4: Stratagems, Communication and Protocols Stratagem 5: “to plough the sea unknown to the skies” or “Deceive the heavens to cross the ocean” At a prescriptive level, the stratagem is used when for example: • patient has anger problem: monitor your level of anger and apologize before the explosion • patient who needs to report to ACS, probation officers, etc…: How can you manipulate them? Could you ask them for advices? If you can save your children, they will save you! • Patient who wants to work at a too early stage: Why don’t you try to become an addiction counselor? With all your experience you’ll be an asset. How can you help your uncle with his alcohol problem? Observe and report, it will help you in your future career. • Patient who wants to stop using: Let’s scheduled your chaotic or carnival day.

47. Part 4: Stratagems, Communication and Protocols Stratagem 6: “Lead the enemy up to the attic and then remove the ladder” This stratagem can be seen as being the whole objective of the therapeutic work: • having patients resume (or start) being active in the world and start to interact appropriately with others. • When they will experience positive interaction and outcomes from their own actions, the ladder is removed as a new reality is created. • These steps needs to be made slowly: they are like a lost person in the desert who just find an oasis. When progress has been observed in the interaction with the 3 dimensions: • “how can you ruin what you have been able to create until now?” (another way to further remove the ladder) • If they relapse we can reframe positively with: “from winter to summer”

48. Part 4: Stratagems, Communication and Protocols Stratagem 7: “Killing the snake with its own poison” This is the most used stratagem with this population. At a strategic level with the patient: • we are not going in opposition with them but we follow them until they trap themselves in their own contradictions. • Like in martial art where one uses the force of his enemy to make him fall down. In a more prescriptive way: • To offer patients a weapon to kill all the nasty, aggressive, negative people (judge, parole officer, administration workers, husband, wife, etc…). • When ready to use gentleness to kill others, they will be surprise to not have to “kill” anybody and to experience others’ gentleness. • Now, that the patient believes that he is able to kill the “snakes” and that he is respected, he will continue dealing with others for his own benefit.

49. Part 4: Stratagems, Communication and Protocols Stratagem 8: “creating from nothing” When? • When the patient has significantly improved his drug consumption, • and has been able to communicate and relate to others in a functional and balanced way. How? • “As If” • The scales • At the beginning by allowing a daily pleasure as a reward Prophecies: • “if you can save your children, they will save you”. • “You need to convince others in order to convince yourself”. “self esteem is always created in relationship with others”. • “Yes, I know, you did not come for a while but life is outside not in this office… the more you are interacting outside the better it is”. • “If you are able to tolerate others’ weaknesses, you will be able to tolerate yours”. • “You already have an internship: help you Uncle with his alcohol problem it’s the best path to become a counselor”.

50. Part 4: Stratagems, Communication and Protocols Communication & Relationship • communication and relationship are based on the stratagems used to reach the objectives and to solve the problems. Communication aims to • Reframe • Encourage actions and • Forester interaction with the world and others. • Provide positive feedback on whatever are the outcomes of actions or events. Relationship is • Different with Spiderman and Gollum. • With the objective of minimizing distance and differences (we are both human with legs, head, etc…) • To steadily refocused the patient on the objectives and rules (tolerance 0 with violence, etc…)