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Christian Moretto, LCSW, MBST

The Brief Strategic Therapy Model and the Treatment of Drug Addiction: the 3 main myths and some proceeding intervention strategies. 1 st World Conference of Brief Strategic and Systemic Therapy FROM THE ART TO THE TECHNOLOGY OF CHANGE PALAMONTEPASCHI  - CHIANCIANO TERME       

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Christian Moretto, LCSW, MBST

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  1. The Brief Strategic Therapy Model and the Treatment of Drug Addiction: the 3 main myths and some proceeding intervention strategies 1st World Conference of Brief Strategic and Systemic Therapy FROM THE ART TO THE TECHNOLOGY OF CHANGE PALAMONTEPASCHI  - CHIANCIANO TERME        NOVEMBER  10-11-12-13-14,    2010 Christian Moretto, LCSW, MBST

  2. An idealist is one who, noticing that a rose smells better than a cabbage, concludes that it will also made a better soup H.L. Mencken

  3. “between 60 and 80 percent of people who meet criteria for addiction in their 20s are no longer heavy, problem users in their 30s”. Gene Heyman, Research Psychologist at the Harvard Medical School The idealists are precisely those who are continuing… They did not keep any minimal balance in their lives

  4. We call the idealist in the field of drug addiction Chronic drug users who have sacrificed their • Lives • Health and mental health • Family • Career • Money • Freedom • Education, etc… to their utopia They are not able to collaborate nor to resist to the treatment… drug has become their lives…

  5. The attempted solution: “la fuite en avant” or “the retreat forwards” “Drug addiction is a very good example of a confusion that is working like Russian dolls […] at the beginning it’s a solution to a problem, in fact to all the problems, before becoming the problem. When the doctor “cure” the addict and […] has removed his solution, the addict finds himself back with the initial problem that lead him to use drugs.” Jacques Barsony

  6. The first idealist: 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)

  7. The first idealist: Spiderman or “I need a boost (the sting of a radioactive spider) to do the impossible” • They perceive themselves as clumsy, and socially inadequate with the opposite sex, friends, school, work, family, etc... • Or they want to be always at the top and on demand • They have the tendency to focus on what they should be, how they should be, how things should be easy for them to do, how they should enjoy when they want…

  8. The first idealist: Spiderman or “I need a boost (the sting of a radioactive spider) to do the impossible Logic of belief • “There is something that will give me the strength, the will, the courage, the control…” Logic of paradox • “I can have control over something that I put in myself”

  9. Like Spiderman, the more they retreat forwards in their artificial ability to jump from one skyscraper to another, the more their fall is vertiginous and landing is painful...

  10. The second idealist: Gollum or “let me enjoy “my Precious” alone in my cave as the world is a nasty place.” • They are abusing depressants (heroin, alcohol, benzodiazepine, etc…) to be able to live in their caves and enjoy their “precious” utopia.

  11. The second idealist: Gollum or “let me enjoy “my Precious” alone in my cave as the world is a nasty place.” • They all share the tendency to put the blame on their partners, the family, the society, genetics, laws - but rarely on themselves. • 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.

  12. The second idealist: Gollum or “let me enjoy “my Precious” alone in my cave as the world is a nasty place.” Logic of contradiction • “The more I withdraw, the more I feel secure” Logic of belief • “I can live without others and the world”

  13. the more they retreat forwards in their cave to enjoy the idealistic power of their precious, the more others and the world seem far away from their ideal and the more they will retreat

  14. the third idealist: The Sorcerer Apprentice or “I want everything and its opposite and without any effort” • These patients use cocaine or any kind of stimulant 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).

  15. the third idealist: The Sorcerer Apprentice or “I want everything and its opposite and without any effort” Like the sorcerer apprentice (Fantasia – Walt Disney) they look for: • the easy way to do all the chores, enjoying Life’s pleasures, and be at the top without making too much of an effort, and…

  16. the third idealist: The Sorcerer Apprentice or “I want everything and its opposite and without any effort” … enjoy the quietness and comfort of a retreat from the world where they can dream of infinite power over the elements and the world.

  17. the third idealist: The Sorcerer Apprentice or “I want everything and its opposite and without any effort” Logic of paradox • “I can have the control over products that I put in myself, over their mixture and over their effects” Logic of belief • “There is something that will give me the strength, the will, the power… and the quietness”

  18. Like the sorcerer Apprentice, they are the champions at pushing up and then pushing down believing that they can keep the control of external and internal realities…

  19. The basis of a protocol: Gollum • Very close to the Moralist in the Depression Area (Muriana, Pettino and Verbitz) They share with the Moralist : • paranoiac ideations, anger, • Passivity and aggressiveness • resentment, unending grieving, • inability to compromise because of their rigid belief system, • Practical renouncement, • Fight using their mind but not concrete actions. • Mumbling, complaining, victims…

  20. The basis of a protocol: Gollum The relationship is key • At the beginning at least, the therapist needs to follow the patients with what his problems are outside of the drug area and to work on them • At the same time, therapist needs to gently reframed patient’s perceptions of others and the world • Use of soft humor

  21. The basis of a protocol: Gollum Generally patient’s reported problems are: • Depression • Compulsion to think, racing doubts • Panic attacks • Unending grieving • Paranoid ideations • Complete loneliness or at the opposite others, family, etc. • Very rarely their precious!!!

  22. The basis of a protocol: Gollum Use of reframing, metaphors and story telling & Use of the protocols that are fitting their main issues • Writing letters • Kill the snake • Anthropologist of the signs of others’ refusal • Blocking replies • Souvenir gallery • Bumper technique • Etc…

  23. The basis of a protocol: Gollum We can introduce the story of the ostrich and the lion • On another side, I wonder how they managed to survive until now? • Can you find out for me? • Give more exploration tasks and explore activities, pleasures, past hobbies, desires (if any)

  24. The basis of a protocol: Gollum Continue with the stories of • Count Hohenstaufen and the quest of God’s language • Cast Away / Robinson Crusoe • Aphorisms on renouncements… At one point, the drug issue will come up and at that point… • Go slow and frustrate to increase • “I am very concerned with what will happen to you if you lose your cave, your bucket of sand, your precious…? You won’t be able to survive outside…”

  25. The basis of a protocol: Gollum • Then reluctantly offer to go to a detox or a detox/rehab program: before going, prepare activities and plans after discharge • Organize and plan visits to the cave • Work with Psychiatrist on prescribed medication • May need to work on the guilt and regrets associated with what they missed and lost during all those years (reframing, aphorism,…and direct them on another action)

  26. Beth: “I want my Xanax”  • 60 years old AA female • Heroin addict for 10 years and on methadone for 10 more • 3 daughters • 8 grandchildren • At 50 y/o found a girlfriend • On Xanax for the past 5 years • Admitted because of intoxication episodes

  27. Beth: I want my Xanax One episode of intoxication When there is a crisis: intoxication or even suicidal threats • Took the complementary stance and make the hidden obvious (circular against linear and linear against circular) • Medical • 911 • Made the world enter their cave Then with “lying by saying the true” explained that • “Sorry, I was very concerned for your health!”

  28. Beth: “I want my Xanax” Russian doll like succession of issues • “Peculiar Phobias”: fear of dog excrements and fear of statues • “I do the things but I’ll keep my Xanax!” • Conflict with daughters as she unable to say “No!”, then anger and verbal explosion

  29. Beth: “I want my Xanax” • “I feel better and I will buy a car” • Agreed to progressively decrease medication dosage • Negotiation with the car dealers • Get her driver license back • Decided to move in with her girlfriend • Guilt: “you are the patriarch and the living memory of your family” • Takes care of grandchildren and went for a trip with her car down south

  30. Beth: “I want my Xanax” • At discharged Beth was maintained on a minimal dosage of Klonazepam

  31. The difficult things to do in the world need to be tackled at the stage of their easiness, and likewise big things in the world need to be tackled at the stage of their tinyness. François Jullien, a Treatise on Efficacy

  32. Bibliography • Nardone G.,Giannotti E., Rocchi R.(2007), The Evolution of Family Patterns and Indirect Therapy with Adolescents, Karnac Books Ltd,London UK • Nardone G.,Salvini A.(2007), The Strategic Dialogue, Rendering the diagnostic interview a real therapeutic intervention, Karnac Books Ltd,London UK • Nardone and Portelli (2005). Knowing through Changing: The Evolution of Brief Strategic Therapy. Crown Publishing House, UK. • Jacques Barsony (2010). Lettre ouverte aux drogués et aux autres s’il en reste. JBz & Cie, Paris, France. • Branca Skorjanec (a cura di). Come smettere di fumare (2008). Ponte Alle Grazie. Milano, Italy. • Matteo Papantuono & Claudette Portelli. Brief strategic-systemic approach to cannabis addiction (2008). Communication at the “International Congress of Brief, Strategic & Systemic Therapist ” San Diego, Ca. • Nardone and Watzlawick (1993). The Art of Change: Strategic therapy and Hypnotherapy Without Trance. Jossey-Bass Inc. San Francisco, CA.

  33. 74 patients (40 males and 34 females) with 6 dropouts. • Chronic users (generally more than 10 years) • From October 2005 to July 2008 • At the end of June 2010, a total of 115 patients have been treated

  34. Substances abused at intake

  35. “Life” Problems at Intake

  36. Mental health diagnosis at at Intake

  37. Treatment Outcome Drug Treatment

  38. Treatment Outcome Treatment of “Life” Problems

  39. Major Major Partial Partial No No Improvement of “life” problems Improvement of “life” problems Among the 54% with successful Drug treatment (N=37) Episodic consumption Complete Abstinence

  40. Major Major Partial Partial No No Improvement of “life” problems Improvement of “life” problems Among the 34% having No Significant Improvement in Drug Consumption (N=23) Minimal change in Drug consomption No change in Drug consomption

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