[Addiction and brief-systemic therapy: working with compulsion].Encephale 2009; 35(3):214-9E
In our daily practice in public hospitals, we are regularly confronted with the paradox of helping patients, who do not ask for help. Although the French law is clearly defined to allow us to treat patients suffering from psychiatric conditions, who are unable to give their consent, it is not the case for those with addictive disorders. In fact, their disorder does not always (or does not yet) justify treatment without their consent, according to the 1990 law (psychiatric treatment without the patient's consent). However, many of them are referred to us because a third party has forced them (spouse, general practitioner, treatment order) and even though some patients consult spontaneously, they often do so more "for others" than for themselves. Because of this, the therapist (doctor, psychologist or nurse), in addition to the paradox of treating patients who do not ask for treatment, find themselves in a situation with two-fold compulsion, fixed by the social (or family) setting, both as a helper and as a coercive agent, thus, putting the fundamental concepts of treatment into question. A therapeutic agreement, free-will and motivation are in jeopardy when the pressure is strong, which removes the therapist from his mission of treating. Although we would not question the necessity for psychiatric treatment in patients who do not ask for it (addictions are a major public-health problem), we should not forget that motivation is one of the essential elements for making any changes in behavior. Although compulsion (external or internal) is recognized by everyone as a limiting factor, we would like to show here how much it can be a lever for change, as long as this compulsion is identified right from the first meeting with the patient, who consults in an addiction centre. Brief systemic therapy may be of interest for these patients, since it reinforces the motivating approach, which is recommended today and since the compulsive nature of the request for treatment is not an obstacle for such treatment to be started. We try to outline here how the therapist can get out of this two-fold compulsion and help the patient to become the instigator of this change, often imposed on him. Two elements are fundamental to understand the function of brief systemic therapy. First of all, "systemic" means "interaction". A systemic approach to treatment requires working in clinical situations, particular attention being paid to interactions. Second, brief therapy does not mean short therapy, but rather therapy with an objective in view. The objective is determined by the patient together with the therapist and they work out together how to reach it, with or without the family's help. Because of this, we use a five-point assessment to offer a concrete response to the patients in these psychotherapeutic consultations. Firstly, is the patient the one who has asked for treatment? We know that in addictive behavior, it is not always the one with symptoms who asks for help (many couples consult who are persuaded that the other one needs to change). Once we know who has asked for treatment, we clarify (with the patient's help) that his/her objectives are not the same as someone who asks for treatment and we can then redefine them (first step in the therapeutic agreement). Once the request for treatment is clarified, we can clearly define what the problem is, the objectives that the patient fixes for him/herself and how to reach them. A large proportion of therapeutic failures result from the request for treatment being unclear. In this way, we define the problem in concrete terms, without using classifications and the previous attempts to solve it (third point). In fact, we often find that the problem itself is the solution, which is chosen to try to resolve it. Knowing which solutions have been tried (and failed) allows the patient to realize what is effective and what is not. The role of the therapist is to help the family and the patient to find other types of solution to their problem. The therapist only offers concrete tasks, which can be done in the near future (minimal changes). Finally, the therapist takes into account the patient's beliefs, values and personal priorities, to which they are attached and which have determined up to now, how they react to the problem. To work with a patient suffering from addiction, it is important, first of all, to find the elements of compulsion, which are hiding behind each request for treatment. This is because, if the patient does not follow the initial therapeutic objectives, there is always the underlying complaint, which should motivate the patient to improve the situation. An individual patient only has a few possibilities for adapting to this type of situation (agreeing, refusal or negotiation) and the role of the therapist is first of all to help him to realize this. This helps to avoid resistance developing, by underlying the compulsive aspect, which originates from the family's request for treatment. We offer a way for setting up the first meeting: working on the role of the patient in the treatment. Three types of patients consult: patients who are "not concerned" (sent by a third party; their main problem is with the person who asked for them to be treated), "victims" (they complain and consult because they put the responsibility of their problem on someone else) and "clients" (they consult because they consider that their problem depends on themselves and they want help to solve it actively). In fact, changing is not easy and does not happen without making an effort. Change comes from a complex cycle of interactions, for which it is often impossible to find a single origin for the situation in question. The psychological world tends towards homeostasis, just like all human systems, and so, suggesting making changes can only be experienced as an intrusion. Pathology begins when an individual can no longer choose what he/she needs to do. We do not consider that a brief-concrete approach is better than any other approach, but its pragmatic nature seems to fit in with the new conception of addiction therapy, with earlier intervention. However, is it possible to make changes outside of a crisis situation? We are unable to answer this question, except to say that the best time for change is that chosen by the patient.