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

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Application of the Brief Strategic Therapy
Model to the Treatment of Drug Addiction
International Congress of Brief, Strategic
Systemic Therapists San Diego, CA September 12
13, 2008

• Christian Moretto, LMSW, MBST
• Family Therapist, ASAS/WMMG
• Director of Strategic Therapy Interventions of
  NY
• http//www.strategic-therapyandinterventions.com

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Part 1 The Place The Study

• Outpatient Alcohol 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.

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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.

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Part 1 The Place The Study

• Life Problems at Intake

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Part 1 The Place The Study

• Mental Health Cluster

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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.

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Part 1 The Place The Study

• Substances Abused at intake

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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.

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Part 1 The Place The Study

• Profile of an average patient

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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).

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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 gt60 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 60gtProblems solvedgt30
• 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 solvedlt30
• Among the problems observed at intake or during
  treatment less than 30 are solved or in process
  of being solved.

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Part 2 The Results

• Treatment of Life Problems Basic results

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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)

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Part 2 The Results

• Criteria
• b- Drug addiction
• Major Improvement Drug consumption is reduced by
  gt60
• 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.

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Part 2 The Results

• Drug Treatment Basic results

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Part 2 The Results

• Drug Treatment Basic results
• There is no balance in drug addiction treatment
• its 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.

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Part 2 The Results

• Combination of treatment outcomes on
• "Life" Problems and Drug Consumption

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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.

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Part 2 The Results

• Among the 54 with successful Drug treatment
  (N37)

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Part 2 The Results

• Among the 54 successful Drug treatment (N37)
• 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).

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Part 2 The Results

• Among the 34 having No Significant Improvement
  in Drug Consumption (N23)

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Part 2 The Results

• Among the 34 having a No Significant Improvement
  in Drug Consumption (N23)
• 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.

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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)

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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 is meaningless as
• 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, its when they
  come back to life that problems resume
• Therefore, it would be a mistake treating only
  one aspect (drug) at a time.

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Part 3 Perceptive Reactive System Attempted
Solutions

• Lifes Basic principle keep a smooth balance

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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,

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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 dont renounce to their Utopia, they simply
  have found other ways.
• Drug users perceptive-reactive system is based
  on the myth of a lost paradise.

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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)

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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.

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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

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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

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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)

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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  

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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.

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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)

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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

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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.

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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 control over ones 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 control over 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.

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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.

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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).

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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.
• Its the equivalent of a reframing as it goes
  against their rigid perception and surprises him.
  
• Irony and humor.

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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 (circular against linear)
• With lying by saying the truth and playing the
  naïve I thought you were sick and close to
  die (which is partially true).

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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 Im joking,
  Im kidding its not true or by laughing
  loud to make them understand that its a joke.
• I thought you were dying..
• When a patient explain that he likes his life
  youre right, and I dont 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 patients premises or on what he is expecting
  or believing from the situation or from others.

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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 patients problems when he
  presents it.
• If the patient does not present drugs as being an
  issue
• Its better always to avoid you only need to
  stop using.
• Its 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 patients assumptions and
  premises and we thereafter make him perceive his
  reality with a different perspective.

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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 lets manipulate the manipulator.
• At a communication level this stratagem is used
  through the systematic use of
• metaphors,
• aphorisms,
• story telling,

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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 dont you try to become an addiction
  counselor? With all your experience youll 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 Lets scheduled
  your chaotic or carnival day.

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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

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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.

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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 its the best path to
  become a counselor.

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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)

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Part 4 Stratagems, Communication and Protocols

• Communication Relationship
• Communication needs to be precise at the
  beginning and focus on the objectives
• But also to be fluctuant on its focus and on its
  topics.
• flexibility and surprise are key factors
• It gives ways to experience a different kind of
  relationship and way to communicate differently
  (learning by doing)
• When a patient is expecting you to do something
  because its your job I have the same credo
  than the one of my mother, I will give you only
  if you deserve it lets see what needs to be
  done

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Part 4 Stratagems, Communication and Protocols

• Communication Relationship
• flexibility and surprise are key factors
• When a patient is not following the rules it is
  important to go back to the rules and have them
  experience the full consequences of his actions
  tolerance zero with threats, verbal and physical
  aggression.
• When a patient is involved in any legal
  supervision (ACS, parole, probation, mandatory
  treatment) You cannot trust me as I will have
  to report the facts and only the facts. This
  simple manipulation increases patients trust.
• In the same way than with the treatments for
  pathologies without drug addiction, the
  relationship evolves towards more friendly,
  formal, and natural interactions that follow the
  patients progress.

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Part 5 The techniques

•  1- Reframing, reframing, and reframing
• Reframing is a very important tool used in
  therapy with this population.
• Reframing is used almost constantly and
• in every settings individual and group sessions,
  and informal meeting.
• To give a different perspective
• on what happened, what is happening, what will
  happen,
• as soon as what the patient is saying carries a
  potential decrease of his actions in the world
  and with others,
• When communication is embedded in his rigid
  perceptive reactive system avoiding,
  withdrawing, the shoulds, the symmetries, the
  false believes, etc
• Story telling and aphorisms are used in the same
  objective reframing a belief or a situation by
  giving to it another perspective in order to
  change the actions.
• A training on the basics of marketing to reframe
  their illusion on drug consumption

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Part 5 The techniques

•  1- Reframing, reframing, and reframing
• Examples of reframing
• Whatever you are white! - No, no, no, I am
  French!
• This one is not a good therapist, and this one
  is a bad MD and you, are you a good patient?
• Did you use drug in your life? Then how can you
  help us? When I was in my twenties I wanted
  to become a gynecologist, now I am happy that I
  have changed my mind

55
Part 5 The techniques

•  2- Other protocols and prescriptions
• the whole range of Brief Strategic protocols and
  interventions developed by Giorgio Nardone and
  his team in Arezzo have been used
• Anxiety disorders (panic attacks, agoraphobia,
  phobias, PTSD, OCD )
• Obsession and compulsion to doubt
• Sexual dysfunction
• Relational and communication issues (with every
  patients)
• Couple, family, parenting
• Grief
• Depression
• Even eating disorder (no anorexia or vomiting
  syndromes)
• Gambling
• Presumed psychosis
• Paranoia 

56
Part 5 The techniques

•  3- Story telling
• During individual and group sessions with the
  same old objective reframing patients rigid
  perceptive reactive system and increase they
  potential for action and interaction with others
  and the world.
• Examples
• Fear of others judgment The man, his son and
  the donkey
• I used because life is too hard In Africa there
  is an animal called the Ostrich If I understand
  well you are choosing the ostrichs strategy to
  face this problem I wonder how they have been
  able to survive for so many years
• Killing the snake the 2 guys at the subway
  station

57
Part 5 The techniques

•  4- aphorisms
• One of the way to modify the perception and
  thereafter the reaction of any patient.
• Aphorisms are very powerful as they are like
  picture and bring to a different perception and
  emotion.
• Weekly relapse prevention group starts with two
  aphorisms who always have the same objectives
• make the hidden obvious,
• increase action and activity,
• reframe belief system,
• and advertise for consistency of action and
  perseverance.

58
Part 5 The techniques

•  4- aphorisms examples
• Start by doing the necessary, then whats
  possible and suddenly youre doing the impossible
  -saint Francis of Assisi
• Insanity doing the same thing over and over
  again and expecting different results. - Albert
  Einstein
• The weak can never forgive. Forgiveness is the
  attribute of the strong. Mahatma Gandhi
• I haven't failed, I've found 10,000 ways that
  don't work - We now know a thousand ways not to
  build a light bulb Thomas Alva Edison
• We cannot change anything unless we accept it.
  Condemnation does not liberate, it oppresses. C.
  G. Jung
• A journey of a thousand miles starts with the
  first step. Tao
• Some people change when they see the light,
  others when they feel the heat.--Caroline
  Schoeder
• The living are soft and yielding the dead are
  rigid and stiff. Living plants are flexible and
  tender the dead are brittle and dry. --Lao Tzu
• It is not the strongest of the species that
  survive, nor the most intelligent, but the one
  most responsive to change. --Charles Darwin,
  (1809-1882)
• In a consumer society there are inevitably two
  kinds of slaves the prisoners of addiction and
  the prisoners of envy. -- Ivan Illich

59
Part 5 The techniques

•  5- New prescription and the basis of a protocol.
  
•  
• 1- they are constantly intoxicated
• The strategy is to use the same logic
  (contradiction) than the Attempted solution,
• Then the intervention will be to make public what
  or who is willing to hide
• Until the patient goes to detox/rehab.
• Each time that an intervention of this kind has
  been made, patient has gone to detox/rehab in the
  following weeks or have radically change their
  substance abuse patterns.
• Gollum and Spiderman and Sorcerer Apprentice  

60
Part 5 The techniques

•  5- New prescription and the bases of a protocol.
  
•  2 - they are able to interact with others and
  therapist in a some sort of way  
• They are rigorously avoiding the drug issue They
  are in denial and therefore very linear.
• work on what is the presenting problems with the
  same objective to increase interaction with
  others and the world
• Work all around what is denied without directly
  touching it until the patient suddenly lift the
  veil of the secret object.
• The post-it block metaphor
• for Gollum, Spiderman and Sorcerer Apprentice.

61
Part 5 The techniques

•  5- New prescription and the bases of a protocol.
  
• 3 The Spiderman myth  
• they are abusing drugs, are dependant but are
  able to interact with others and therapist in a
  decent way.
• They are aware that drug is playing a big role
  and they are willing to do something about it.
• Prescription
• reframing their addiction using a new belief
  they are like society, complex system, they need
  a carnival day, chaos to maintain the whole order
  and have the strength for the rest of the year.
• Patient will have to organize a carnival days
  twice a week
• At that moment, he will have the choice to take
  cocaine or not (logic of paradox).

62
Part 5 The techniques

•  5- New prescription and the bases of a protocol.
  
• After a couple of month we ask patient to move
  the chaotic day that is not a Saturday forward.
• When we arrive at having 2 carnivals on Saturday
  one is suppressed and the patient is having only
  one chaotic day every a Saturday.
• After a couple of months and a further increase
  of negative toxicology screens and improvements
  of his life, patient comes to us willing to stop
  completely, he is at 7 or 8 on a scale of life
  issues and wants to go further.
• We ask him now to trick the system and to do his
  carnival day the day after a toxicology screen.
  At that point, the patient presents only negative
  toxicology screens and stops using cocaine.

63
Part 7 Conclusion

•  
• 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

64
Part 8 Bibliography

• Muriana, Petteno, and Verbitz (2006). I volti
  della depressione Abbandonare il ruolo della
  vittima curarsi con la psicoterapia in tempi
  brevi. Saggi di Terapia Breve. Ponte Alle Grazie,
  Italy
• Nardone G., Salvini A. (2007), The Strategic
  Dialogue, Rendering the diagnostic interview a
  real therapeutic intervention, Karnac Books
  Ltd, London UK
• Nardone G., Giannotti E., Rocchi R. (2007), The
  Evolution of Family Patterns and Indirect Therapy
  with Adolescents, Karnac Books Ltd, London UK
• Nardone and Portelli (2005). Knowing through
  Changing The Evolution of Brief Strategic
  Therapy. Crown Publishing House, UK.
• Nardone and Watzlawick (2005). Brief Strategic
  Therapy Philosophy, Techniques, and Research.
  Jason Aronson Inc. Northvale, NJ.
• Nardone and Watzlawick (1996). Brief Strategic
  Solution Oriented Therapy of Phobic and Obsessive
  Disorders. Jason Aronson Inc. Northvale, NJ.
• Nardone and Watzlawick (1993). The Art of Change
  Strategic therapy and Hypnotherapy Without
  Trance. Jossey-Bass Inc. San Francisco, CA.