Case Conference: Master Clinicians


Using a case presentation as a starting point, three well-respected addiction psychiatrists presented their formulations and treatment approaches. Presentations focused on how patients are treated along a spectrum. Dr. Jeffrey Wilson presented a case history of a young patient whom he had treated. Dr. Edward Kaufman presented a treatment phase-related view of a counter transference model of therapy and applied it to this patient. Dr. Peter Steinglass discussed a family systems approach for this patient. The audience was then invited to comment on the case. In addition, some members of the audience presented a brief overview of some of their cases followed by reactions from members of the panel.

Symposium Chair: Michael M Scimeca, M.D, New York, NY

Edward R. Kaufman, MD, South Coast Hospital, Dana Point, CA; Peter Steinglass, MD, Ackerman Institute for the Family, New York, NY; Jeffrey J. Wilson, MD, New York State Psychiatric Institute, New York, NY

Presentation of the Case

Dr. Wilson: Mollyís father called for an appointment for his 17 year old daughter, 4 weeks after she cut her wrists in a suicidal gesture. He wasnít aware of any precursors to this event and re-quested an immediate appointment. Molly came alone to her first appointment and reported multiple family stressors on the day of the suicidal gesture. She also reported a 4-month history of increasing depression and irritability.

The patientís substance use history included: smoking marijuana several times daily for the prior 6 months; history of ketamine abuse, last used 9 months ago; no other drug use; abstinent for past 7 days; attended two Narcotics Anonymous (NA) meetings.

Current functioning included: A- / B+ student; working part-time in a clothing store; oldest of seven children and helping frequently absent parents with 6 younger siblings; always considering herself last; feeling very guilty about substance use and misconduct.

She reported a family history of finding bottles of vodka in the commode on several occasions due to maternal alcoholism. Her paternal grandparents were alcoholic. Molly is a "parentified child". Her mother had an affair last summer with a college student. Her father is a devout Christian and child of an alcoholic.

Developmentally, Molly has had normal milestones, above average academics, and strong social skills. She went through puberty early, and reported incidences of depression with no manic episodes. She reported adolescent-onset conduct problems including stealing from parents and lying as well as shoplifting and fighting in school. She started using marijuana and designer drugs in 10th grade and this use increased considerably over the summer, particularly after motherís infidelity. In 11th grade she began attending church group and stopped using drugs. She quit the a church group in spring, feeling depressed and that it was not helping. She then began smoking marijuana daily. Mollyís mental status included provocative dress and generally upbeat demeanor, despite reported dysphoria; conduct problems including stealing for which she felt terribly guilty; over-whelming sense of responsibility in context of powerlessness and unmanageability.

Her DSM-IV diagnosis was: Axis 1: cannabis dependence, depression probably secondary to cannabis dependence, major depressive episode, and conduct disorder; Axis 2: deferred, borderline traits; Axis 3: none; Axis 4: moderate family stressors including maternal alcoholism, large family, limited parental supervision; and Axis 5: Global assessment score was about 60 out of 80 in the last six months.

The formulation of the case included highly responsible, "parentified" child becoming increasingly ambivalent about her role within the family. Her externalizing behaviors creates guilt but also has adaptive value in individuation from the family. The suggested treatment plan was: 1)12-step facilitation type therapy, with meeting list, sponsor, and starting to work on the first step; 2) sertraline treatment for depression; 3) supportive psycho-therapy; 4) family therapy.

Her treatment course was not successful. Molly had difficulty changing peer groups. She did not sustain NA and marijuana use in-creased along with her sense of powerlessness. There was little family support. The mother came to a session after eight weeks, intoxicated; entered detox but didnít sustain rehabilitation. Molly had difficulty relinquishing responsibilities. A higher level of care for Molly was recommended, but the patient and family were concerned about confidentiality. The patient discontinued treatment.

Re-entry into treatment after 8 weeks was triggered by a crisis incident. Molly was found by police and the school principal to have dilated pupils and was brought to the ER. Soon after, at a party she had a blackout, awakening in bed with a couple of friends without her pants or underwear. However, in treatment the family remained reluctant to have Molly go to day treatment or a therapeutic community. So treatment was redesigned including urine drug screens, but the family was unable to sustain weekly therapy.

Questions: 1) What is the best approach for this patient? 2) How can a clinician sustain this youthís initial enthusiasm? 3) When a family is unable to sustain your interventions, what is the next step?

Discussion of the Case

Dr. Kaufman: This is a very difficult case where many in the family have psychopathology and are not highly motivated. In this era of managed care it is difficult to devote the time that is required to help a family like this. "A measure of marginality," the theme of this conference, needs to be continued by using models that are integrative and inclusive, but also flexible. This is a presentation of a model called treatment phase-related view of counter transference. It has three phases, which include: 1) achieving abstinence, 2) early recovery and, 3) sobriety or advanced recovery. The focus here will be mainly on the first phase.

To achieve abstinence, first we assess the consequences and extent of the substance abuse. In the family setting we assess the substance abuse and the psychopathology of every family member, as well as roles and communication patterns of the family. We need to appreciate the uniqueness of each family system and each individual in the family. Families differ substantially on many parameters: generation, age, culture, ethnicity, number of siblings, the substances abused.

Molly is typical of the oldest child in families like thisóthe parental child, who takes care of others and doesnít meet her own needs; getting immediate gratification through drugs, including relief of depression and relief of pain and responsibility. We need to examine some assumptions about the typical patterns in these substance-abusing families. Mollyís drug abuse is just the tip of the iceberg. There is a lot of depression that precedes her substance abuse and that is being self-medicated with drugs. She also has primary substance abuse with tremendous genetic loading. Even if there were no substance abuse, there would be codependency in this familyómotherís affairs, daughterís suicidal behavior.

Once the assessment is made, a viable treatment contract must be developed. Detoxification and abstinence must be insisted upon as a condition of psychotherapy. With the mother we need to insist on detoxification immediately. With the daughter we have more time to achieve abstinence. In my experience, 12-step groups work better for sustaining abstinence than any other method. However, finding groups that youth can identify with can be a problem. Other methods can be given as choices such as religion, that is all encompassing, and pharmacotherapy such as antabuse, naltrexone, buprenophine, and methadone maintenance are all ways that can help people let go of drugs. This patient needs a comprehensive treatment plan that might include day treatment. However, it is difficult when that is refused. In his work on heroin addicts, Duke Stanton presented techniques to bring patients in, e.g., paying them, aggressive telephone outreach, and even a home visit.

The treatment contract encompasses family participation in the diagnosis and treatment of any underlying psychiatric disorders including taking the medications needed. The therapist might start by saying that treating a patient like this is rarely successful unless the whole family agrees to stop drinking for at least the first year. However, this approach would be difficult in a family like this. This family calls for a team approach, including individual work with some family members. Bringing in siblings and including family education is also important. Then a contract can be developed to incorporate all these elements. Since one canít always insist on the contract during the evaluation period, the model needs flexibility. If the whole family does not agree to a contract, then work with the family members who agree to come in. Sometimes the family can be worked with separately before the identified patient begins, using a modality such as multiple family therapy. Then some of the pain in the family can be alleviated and active participation is more likely.

In summary, sustaining Mollyís initial enthusiasm might be done by very empathic history taking and listening to all of the pain that Molly has experienced. There is a tremendous split between her being a very good girl and a very bad girl and one needs to zero in on the pain of maintaining both of these to make that connection with her. The next step is to get whomever one can to come into therapy sessions, without the therapist being an enabler of destructive patterns.

Dr. Peter Steinglass: The family systems approach that will be described starts with the "family" as the patient. The therapist needs to access what is going on inside the heads of each family member. It is particularly the beliefs that family members hold about illness, treatment, psychiatry, life, and substance abuse óthat will either make them willing partners or will lead them to feel that they donít want to cooperate in treatment. If the family doesnít come back to the next meeting, they are sometimes labeled as dysfunctional, not interested or resistant. However, an alternative approach might be to first place the onus on the therapistóthat there is not sufficient understanding about the differing perspectives of each family member to have adequately connected with them. From this perspective, one might wind up thinking of the family not so much as dysfunctional, but rather as having an agenda that isnít yet understood. Such a stance on the part of the therapist is likely to facilitate the creation of a treatment plan that everyone (patient; family; and therapist) can "buy into."

Now let us address Dr. Wilsonís questions from the viewpoint of a person who truly believes in the family systems approach: 1) What is the best approach for this patient? A family systems clinician would say "Who is the patient, the young woman, or the family?" The answer in this case (with multiple substance abusers in the picture) would likely be that "the logical starting point is to focus on the family as the patient, and also propose family therapy as the core intervention around which the treatment plan should be organized."

2) How can a clinician sustain the patientís initial enthusiasm? The answer would be that "the clinician is NOT the important player here, but rather the facilitator of how to mobilize the patient and the familyís enthusiasm." This is a different headset, where we think about the expertise residing in the family, rather than thinking of the therapist as the "expert".

3) When the family isnít able to sustain the therapistís interventions, what is the next step? The family systems therapist would say: "Itís not MY intervention." Instead the way it is framed is that the clinicianís job is to identify and help organize a set of ideas coming from the familyówhat they (the family members) think the issues are, what theyíve tried in the past that is helpful, why theyíre not applying the same problem-solving strategy this time, or why it isnít working, and what ideas can be generated to take a fresh crack at it? Thus, the therapistís job is as a moderator, facilitator, collector, and organizer of ideas from a group of people with different beliefs and ideas.

So, clearly the family systems approach is based on a different set of premises than a traditional addiction model. Hence even the questions a clinician might pose about a seemingly "stuck" clinical case would be framed differently than the ones Dr. Wilson has raised.

What then does the family systems approach look like in action? Here is one ex-ample of such an approach. It was originally designed for work with families in which the identified patient is an alcoholic family member in the parental generation. However, it seems to have salience for a family like the one today, and in fact may be useful for any family with a chronic psychiatric or medical condition in its midst. There are four phases: I. family assessment. II. family-level detoxification. III. post-detox period, establishing a secure environment for change. IV. restabilization and reorganization. Phases I and II are discussed here.

Phase I is family assessment. Pull out all stops to get all members of the family to the first session. Initially, assess the family and then focus on getting individual perceptions. Assess the pattern of substance use, the developmental history of each family member, and the family as a group. The assessment concentrates on the "goodness of fit" between the characteristics of substance use and the developmental patterns of the individuals and the group. Studies show there is a different series of family interactional patterns when the substance is present from when it is notóa kind of dual state quality. From a clinicianís perspective, the behaviors manifested when the substance is present are often thought of as good things, e.g., higher interaction rates, more communication, greater expression of affection, and also a sense that the family is engaging in problem-solving activity. There-fore, we need to get both sets of information about the family. Then the implications of detoxification for the family can be much better understood. Many families believe that they can only access these positive behaviors in the presence of the substance. If detoxification occurs, the family might believe that these needed behaviors will also be taken away. During assessment, the clinician will find it useful to pay very close attention to daily routine and rituals.

Phase II is family level detoxification where the ideas come from the family in the context of a careful examination of the pros and cons of getting rid of the substance. Donít assume that the substance only has negative consequences. The detox idea must come as much from the family as from the therapist. After that, comes the contracting process.

Principles of family level detoxification include: 1) the therapistís stance is use of non-blaming, non-pathologizing language, and collaboration ó joining with the family against the substance. In family terms this is called "externalizing the symptom"ówe all hate this thing and letís join forces against it; 2) the goals of the detox process are to make the biological environment of the identified patient(s) substance-free and to make the psycho-social environment substance-freeóthis includes the family environment as well; 3) the phases of detox include a) the body and the home made substance-free, and b) the substance-free family moving out into the extended family and the world; 4) the techniques that are used include: a) a detoxification contract that is developed with everyone involved, including anticipation of potential problem areas; b) making the contract public, where the family tries this out with extended family or friends; and c) rehearsing the behavior in high risk environments. If you try this and you feel it isnít working you might say to the family "We have a contract that weíve gotten 60% right and thatís not bad for the first try, but letís see if we can work on the rest," or you might say "Maybe we moved too fast or arenít clear yet on why we think this is a good idea, so letís go back to the assessment phase and have that conversation again."

Would this approach work with this family? One could actually be guardedly optimistic about the prognosis here, but it may well be that this family will need to work with several therapists before things finally click. When the breakthrough finally occurs, all the work that preceded it, including Dr. Wilsonís will have set the stage for ultimate change.


2000 Proceedings

2000 AAAP Annual Meeting Proceedings Copyright 2001 AAAP