NADD Bulletin Volume III Number 1 Article 2

Complete listing

A Brief Therapy Approach to Working with the Problems of Individuals with Dual Diagnoses and Their Families

Katharina Anger, Ph.D., Juliet Hawkins, MA

Brief Therapy, a therapy model originally developed by the Palo Alto Group (Fisch, Weakland, & Segal, 1982; Watzlawick, Weakland, & Fisch, 1974), has gained in its reputation globally, but there continues to be confusion about whether such a short-term model has anything to offer when working with individuals who are dually diagnosed. We, at the Brief Therapy Project of the YAI National Institute for People with Disabilities’ Clinic, have found this model of therapy to be a useful approach for working with the problems of our participants and their families. Not only does working briefly, when done well, free up clinicians to help more clients, but it brings potential users of psychotherapy into the process who may not otherwise be interested in a longterm commitment. In addition, the systemic (interactional) foundation of this approach allows the clinician to utilize significant others or care givers to help when individuals themselves are either unwilling or unable to participate in psychotherapy.

To be effective and brief, a clinician is helped by having a clearly defined roadmap of how to proceed. The following steps have been found to be useful in focusing treatment and making it more efficient: One of the most important steps for the therapist is to identify who is a “customer” for change. Much time can be wasted by trying to work with a person who is either uninterested, unwilling, or unable to change. This is especially true when working with the dually diagnosed, who are typically referred by someone else. Often these clients do not see themselves as in need of help, but their behavior may be causing great distress to those around them. For these reasons we choose to work with the person we call the “customer” or “complainant”, defined as the person who is complaining the most about a situation. This person is most likely willing to do something different if this could lead to some change in the problem behavior or circumstance. Often, the complainant can be easily identified. This is usually the person who has made the referral or who is calling for help. Sometimes the situation is less clear, but this can be explored in the first session. For example, if the “patient”, George, states that “Joe thinks I have to work on my anger”, then Joe is likely to be the complainant, at least about the patient’s supposed anger. However, George may be a customer for changing other issues, such as perhaps wanting more independence. A therapist can work with more than one customer in a given case, about either the same or different problems.

Once we have identified our customer, we need to begin the process of helping them define the problem. Although clients are typically ready and able to tell us their complaints, it may take time to clarify the problem in concrete behavioral terms. For example, a generalized complaint such as “I feel depressed” needs to be reduced and clarified, and may perhaps become “I don’t know what to say when my roommate yells at me.” This renders the problem more concrete, as well as more easily resolvable. We have found that being specific in this way helps clients to feel less overwhelmed and hopeless. There can be times when the therapist is faced with more than one complaint. In these cases, it is important to have the client prioritize. We can facilitate this by asking questions like “Would it be a better first step to make new friends, or to get into less fights with your parents?”

The decisive factor of this brief therapy approach is our focus on the attempted solutions. Our assumption is that the very strategies that the client has been using to “fix” the problem are actually maintaining the problem. If these attempted solutions were effective, the client would not be seeking psychotherapy in the first place. In searching for these unsuccessful attempted solutions, we find at a minimum the direction of the intervention we will need to pursue. For example, if a person has been unsuccessfully trying to lose weight by starving themselves, we know that our intervention must in some way involve eating. That is, we look for interventions that run in the opposite direction (180 degrees) from the main thrust of the unsuccessful attempted solutions that the person has been using on their own.

The following is a case example to illustrate these important steps of the model: Howard is a 55-year-old man with an anxiety disorder and mild mental- retardation. Although Howard was initially referred because it appeared to others that he was enduring much abuse by his roommate, Howard did not see this as a problem. He stated that he had very few friends, that his roommate invited him out on Saturday nights, and that this was worth the roommate’s occasional bad moods during the week. However, Howard himself had multiple complaints that he was interested in working on. He demonstrated great difficulty in prioritizing and defining problems in concrete terms. The therapist first worked at sorting through his complaints, which included a poor social life, anger towards his family for not being more involved, and significant social anxiety which prevented him from participating in desired activities. In the end it was this anxiety that Howard chose to focus on first. In breaking down and making concrete the ultimate goal of overcoming his social anxiety and making more friends, Howard determined that a good first step would be to attend a dance. As the dreaded event approached, Howard became increasingly anxious. He attempted to console himself by telling himself that everything would be OK. Others (residence and day treatment staff) contributed by assuring him that he had nothing to fear. These attempts to lessen Howard’s anxiety were not only unsuccessful, but he appeared to be getting worse by the day. The therapist, upon hearing that everyone else was trying to minimize the perceived danger (and that this was making matters worse), decided to focus instead on the many things that could go wrong at such a dance. Howard and the therapist spent several sessions discussing the possibility that no one may want to dance with him, that he could inadvertently spill something on himself or on someone else, and many other potential disasters. Howard was visibly relieved by these conversations, and began developing strategies for the worst case scenarios. When the dance finally arrived, Howard admitted to being nervous but felt equipped to deal with whatever might arise. The therapist remained concerned that Howard not be overly optimistic. During the following session, Howard gleefully scolded the therapist for having been too pessimistic: “None of that stuff happened. It was a great night!” The therapist appeared “shocked” and to this day maintains concern that Howard should be aware of the potential pitfalls as he continues to take on social situations.

We believe that this case example demonstrates our emphasis on being problem-focused as opposed to working on global feelings of distress or dissatisfaction. It is crucial to work on the problem the client is invested in fixing, to ensure that there is sufficient motivation to make changes in behavior. This example also illustrates our efforts as therapists to take positions or suggest interventions that run opposite to what the client (and perhaps others) have been unsuccessfully attempting to do.

References:

Fisch, R., Weakland, J., & Segal, L. (1982). Tactics of change: Doing therapy briefly. San Francisco: JosseyBass.

Watzlawick, P., Weakland, J., & Fisch, R. (1974). Change: Principles of problem formation and problem resolution. New York: Norton.

For more information contact:

Katarina Anger, Ph.D.
Center for Specialty Therapy, YAI
460 West 34t” Street
New York, NY 10001