Muir Wood therapist, David Laing

Pauper in his Palace: Can Integrated Treatment Make a Prince?

David E. Smith, MD, FASAM, FAACT; Michael Wachter, MD; and Jennifer Golick, MFT

The challenge of integrating treatment is not new to the medical world. Any patient struggling with a chronic illness is frequently seen by a team of treatment professionals who attempt to collaboratively address the unique needs of the patient.

Addiction treatment in particular, however, has historically developed along polarized lines, often leading to clashing models of medical, social, or psychological paradigms. The investment in a single model creates a treatment silo. These models—or silos—can fail to integrate, often viewing each other as having an incomplete or incorrect understanding of the same disease they are trying to treat (Havassy et al, 2009). In the following discussion we use case material to illustrate our effort to construct an integrated treatment approach in the adolescent residential chemical dependency treatment setting. You will experience the perspectives of Dr. David Smith, “The Maverick,” who pioneered medical treatment of addiction in the early 1960s through the creation of the Haight Ashbury Free Clinic; Dr. Michael Wachter, “The Paradoxical Psychiatrist,” who spends more time listening than prescribing; and Jennifer Golick, LMFT, “The Intrepid Therapist,” who immerses herself into the family system. The model used to exemplify integration is formally identified as Case Formulation. We will explore this model of integration through the lens of a 16-year-old patient and his family.

The Maverick

Substance abuse in all its forms represents our country’s number one adolescent public health problem (CASAColumbia, 2011). Peak incidence for the onset of Substance Use Disorder (SUD) is ages 15–21, with the leading cause of death in this age group being drug overdose followed by fatal auto accidents, many of which are related to drunk and/or drugged driving.

This surge in drug overdoses has been fueled in large part by the increase in prescription drug abuse in the adolescent and young adult age group, coupled with the recent heroin epidemic in suburbia and rural areas of the US, challenging the traditional view that addiction is essentially an urban inner city problem (CASAColumbia, 2011). Studies have found that 20% of substance use disorders have a co-occurring Axis I psychiatric disorder. Further, there is growing awareness of Reward Deficiency Syndrome (RDS) and co-morbid process or behavioral addictions (Smith, 2012).

Addiction is a very complex brain disease with multiple medical, psychiatric, and behavioral manifestations. Accordingly, medical, psychiatric, behavioral, and social treatment models have evolved, each with the goal of treating addiction through its own separate paradigm. Each model has tended to evolve in isolation, thereby creating treatment “silos.” When I began treating addiction, it was a felony offense to prescribe the necessary medications to detox an outpatient from opiate addiction. Addiction was viewed in a criminal and moral context because of its behavioral manifestations.

Alcoholism, the most common form of addictive disease in our society, saw a counter trend begin in 1934, with the foundation of Alcoholics Anonymous (AA) by Bill Wilson and Dr. Bob Smith. Their famous and enduring publication, The Big Book of AA, was the origin of 12-Step programs, or the “social model” of treatment. During my early years as a physician treating addicts, the American Medical Association (AMA) confirmed medically that alcoholism was a disease but excluded other drug dependencies. The movement for alcoholism recovery came primarily from the East Coast of the US, with formation of the New York Society on Alcoholism—later the American Society of Addiction Medicine (ASAM)—which grew out of the National Council on Alcoholism.

Addictions other than alcohol took a different track, with the formation of Narcotics Anonymous (NA), which evolved primarily on the West Coast, and featured the development of methadone maintenance treatment pioneered by Dole and Nyswander (1965). Parallel to this was the formation of Synanon, the first 12-Step-based therapeutic community. Synanon in turn developed many offshoots, including Daytop and Phoenix in the East and Delancey Street and Walden House in the West. In 1967, the Free Clinic Movement was born with the philosophies that “Health care is a right, not a privilege,” that “addiction is a disease,” and that “the addict has a right to treatment.” It was from that movement that I was able to aggressively address and treat the disease of addiction in all of its forms.

In the 1970s, with the development of recovery/rehabilitation facilities such as the Betty Ford Center, I saw the extension of what was described as the Minnesota Model or 28-day treatment. Physicians working in these programs distinguished patients by disease and according to treatment modalities, thereby exacerbating the “silo” problems of diagnosis and treatment. ASAM dedicated itself to the broad-based study and treatment of addictive disease, hoping to merge these developing silos into more integral approach to diagnosis and treatment of substance use disorders. Twelve-Step programs offered me, as a treating physician, a valuable adjunct to the care of my patients with addictive disease in a clinical setting. They could be combined with ongoing psychosocial treatment as well as pharmacotherapy.

Propelled by The National Institute of Drug Abuse (NIDA), the 1990s were declared “The Decade of the Brain.” This allowed scientific pressure to be exerted upon the treatment communities to develop integrated treatment models because there are “no silos in the brain.” New treatments offered an integrated biosocial/psychological/spiritual/holistic approach, dealing with all aspects of an individual’s neurobiology and life function. This trend in treatment focused on evidence-based and patient-centered treatment, often in conflict with rigid modality-driven programs. Such integrated treatment is particularly important for adolescent early-onset addiction with clinically significant co-morbid psychiatric disorder.

The partitioned approach is particularly counter-productive with dual-diagnosis patients. Dual-diagnosis disorders are defined as the co-existence of a substance use disorder (SUD) and a co-morbid mental illness. According to the 1999 Surgeon General’s report, about one-third of adults with SUD have another psychiatric disorder, while 15% of adults with a psychiatric disorder meet the criteria for an SUD (ASAM, 2000).

The therapeutic approach to patients with a mental illness and a co-occurring SUD is complex, because different therapies are appropriate for different addiction and mental disorders. Dual-diagnosis patients may need medications for their psychiatric disorders and entirely different classes of medications for their substance dependence, such as buprenorphine (Grau-Lopez et al, 2014). Specific research has established that Medication-Assisted Treatment (MAT) of opiate addiction increases patient retention and decreases drug use, infectious disease transmission, and criminal activity (NIDA, 2012). MAT of opiate use disorder is supported by the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Institute of Medicine (NIM), and the World Health Organization (WHO).

The goal is holistic recovery that allows individuals to live productive, fulfilled lives as they effectively manage the symptoms of their disorder. Over the past 40 years of my experience in addiction medicine, I have observed the power of each silo grow and expand. Our current challenge is to integrate the silos into a synergistic and unified approach to treating the addicted population, as is now formally recognized by ASAM (Cavacuiti, 2011). I continue to work toward an integrated, multidisciplinary approach to addiction treatment, and thankfully I am no longer considered an outlier.

The Paradoxical Psychiatrist

As the consulting psychiatrist at Muir Wood Adolescent and Family Services, I will continue Dr. Smith’s discussion from the perspective of his mandate for integrated treatment. Our program relies on the 12-Step social model with our recovery counselors and milieu, a medical model to manage detoxification and other medical comorbidities, a psychiatric model to evaluate psychiatric comorbidities, and a psychological model to effect behavioral change for the adolescents and their families through intensive individual and group therapy. Hence, without a unifying construct, we run the risk of siloed thought and treatment philosophy regarding clients and their families.

The model that we use at Muir Wood to integrate the 12-Step, medical, psychiatric, and psychological paradigms is the well-delineated “Case Formulation.” This model is concisely outlined in psychiatric literature, with a practical discussion of “Its Structure, Purpose, and Application” (Perry et al, 1987; Winters et al, 2007; McWilliams, 2013). We, along with numerous other authors, believe that the collective group construction of the case formulation model creates inclusion through a shared stance of curiosity.

We will use case material of a 16-year-old, dual-diagnosed adolescent and his family to take the reader through the construction of a case formulation. The case formulation is constructed collaboratively with our multidisciplinary team of recovery counselors, physician, psychiatrist, therapist, and clinical director. The forums for contribution include multidisciplinary treatment planning, daily shift reports, individual assessments, and all available relational experiences between program and client/family. To illustrate, a report of staff interaction in a car ride to the gym or an outside meeting may provide data as important as that obtained from the seemingly more formal admitting psychiatric evaluation. These data can fundamentally change or expand the initial formulation.

We also subscribe to the relational view of the treatment experience in the construction of the formulation. This is a contemporary school of psychological thought, with compelling discussion of its value in engaging, retaining, and developing strong therapeutic alliance in adolescent chemical dependency treatment (Mitchell, 1995; Director, 2000, 2002, 2005). The fundamental aspect of the relational model is its focus on the two-person field, thus examining the evolving therapeutic relationship between client and clinician, rather than merely observing the client and family as singular entities. The clinician and the patient are in treatment together.

Case formulation has three main components (see also Smith et al, 2014). The first component includes external stressors. For this client, they include homelessness, substance use, substance induced psychosis, a learning disorder, academic failure, unstable and dangerous peer relationships, ruptured family dynamics, and recent treatment failures—just to name the most overt. Of note, many of these external stressors are individual diagnoses unto themselves, certainly qualifying this patient for dual-diagnosis status.

Frequently, treatment stalls at this juncture, burdened by the high density of external stressors, diagnoses, and a reflex to respond to them algorithmically. Hence, the first part of the formulation is a list of external problems, most of which carry a valid demand for external treatment interventions.

The second part of the formulation is designed to understand the unique psychological makeup of the client and family, which we will be discussing in great detail. It is a comprehensive description of the client’s personality structure, including wishes, fears, and defenses. We believe that the standard treatment interventions cannot be taken up equally or generically by any two clients and must be adjusted to consider the psychological structure.

Of critical importance, data for the second part of the formulation are collected by the interpersonal (or relational) experience between client and clinician. Careful attention is directed toward understanding the subjective experience in the room between client and clinician, even while gathering the “factual” past history and present history outside the room. Close attention is paid to the style or process of the interview, which can be distinct from the content. How a client tells his story is as important as the content of the story. Does the client seem credible? What is his affect? What are his defense mechanisms?

Data to answer these questions come from the internal experience of the clinician conducting the interview. What feelings emerge while listening to the story? How do those feelings affect our line of questioning and thinking? These are long held fundamentals in psychotherapy, collectively referred to as “countertransference.”

The third part of the formulation is to make an early prediction of the client’s response to the total treatment situation, based on the interaction of the client’s personality with the staff and program. The goal of this prediction is to orient us to the client at the greatest available depth of relationship, thereby establishing early engagement and therapeutic alliance.

We will focus the reader on the second and third components, perhaps most usefully considered together as the psychological and relational parts of the formulation. This is distinct from, yet used in conjunction with, the external data described below.

Our client is a 16-year-old boy admitted for severe substance use disorder, including amphetamine-induced psychosis. External stressors are extensive; however, the chief stressor we will explore from a relational perspective is his homelessness. He lives on the street, immediately outside his parents’ comfortable residence, with the assertion that he is a functional adult. He periodically comes home, but the family’s concern at the time of admission is that he is “emancipated,” thereby limiting their ability to admit him involuntarily to treatment. He is, therefore, at the time of admission, a pauper outside his palace.

In my psychiatric assessment, I make note of the subjective quality of the interview:

This is a very engaged adolescent male, who presents himself as extremely mature, autonomous, separated from his parents, and able to live successfully as an adult on the street. His interview style is very controlling in the way he dictates the rate, pace, and contents of the interview. He does not want to be interrupted and has a very organized and methodical way of presenting his story. This does appear somewhat defensive as he is distressed and disorganized by questions that might disrupt the flow of his rigid narrative. This lends a pseudomature quality to his presentation, where he wants to appear “adult” but demonstrates fear and limitation in an adult interpersonal exchange.

Based on my relational experience of the interview, an early, speculative model of the client’s character structure can be formed. I draw on here-and-now dynamics of the interview to extrapolate into past and present relationship style. A general sense of uniqueness begins to form, as no two clients have the same permutations of events, experiences, and relational style. My early prediction in this case is as follows:

In predicting a response to therapeutic situations, we should consider this patient’s pseudomature development, wherein he imagines he can reject his parents and his illness and live as an autonomous adult. This pseudomaturity appears as a centrally organizing defensive stance. He works hard, however, to preserve this stance in the interpersonal context of the interview, lending it a rigid and brittle quality.

 He simultaneously appears relieved to be in treatment and potentially curious about his experience with us and his family. This speaks to underlying wishes for containment and dependency, palpable beneath his thin pseudomature veneer. This poses a conflict about autonomy and dependency, which will likely manifest behaviorally with staff and peers. We can anticipate a broad spectrum of distress as we necessarily make “contact with the conflict” (Vedder, 1993; Bromberg, 1991).

Our clinical director, Jennifer Golick, LMFT, next takes us through the relational experience of the case. She speaks from her personal subjectivity, informed by her immersive interaction with the recovery counselor staff, client, family, medical and psychiatric team, and staff therapist, as well as her own individual and group therapy work.

The Intrepid Therapist

As the clinical director of Muir Wood, I have observed that maturation—in all its aspects—holds tremendous importance in the mind of the adolescent and his parents. What is the rate of maturation? Will the teen reach a point of maturity in relationships, work, self-determination, and autonomy to be successful in the world at age 18? Can he go to college, obtain a job, and begin to live independently with the rest of “adult society”? Here we present a case with a central formulation theme of the maturity or, in this case, the pseudomaturity (Bromberg, 1995; Goldberg, 1995; Meltzer, 1990; Mondrzak, 2012) of an adolescent client and his family.

This case began with several phone calls from the parents during the initial pre-admission screening. The parents, “Shelly” and “David,” sought treatment for their endangered 16-year-old son “Roger” but expressed helplessness in dealing with their perception of his “emancipation to adulthood” at age 16. They described a boy living on the streets outside their residence, truant from school, nearing psychosis with stimulant use, embraced by a homeless peer group, and defying them to intervene as he was “an adult.” Roger was not running away, made periodic visits home, and had essentially declared himself a poor adult living just outside his home, as a pauper outside his palace. The problems of dealing with their poorly developed but “adult” or pseudomature son paralyzed Shelly and David. Their confusion about his maturity then led to confusion about the right context for treatment.

They decided to admit Roger to our program, using adult negotiation to “collaboratively” engage him in the process. David purchased cigarettes for Roger during his transportation in deference to his “adult” status and to “collaborate” on the admission. At one point while they were en route to treatment, Roger initiated a phone call with the executive director to advocate for his ability to smoke in treatment. This was a foreshadowing of things to come, demonstrating Roger’s desire to dictate terms of an adult treatment.

Roger spent the majority of the first weeks talking about prior treatment episodes, comparing and contrasting treatment programs by endorsing what he described as his previously superior treatments, emphasizing his “adult” experience of a brief stay in a sober living environment. He also spoke at length of his “street wife” and “street family,” all of whom were actual adults who had chosen the lifestyle of homelessness and lived in an encampment near Roger’s family’s residence. He frequently referenced these individuals as his chosen family and made regular declarations about his desire to return to them as a relational family of origin rather than his own biological family.

When I began interacting with Roger, I was struck by his need to present himself as a mature adult to staff and other residents. This presentation had an awkward and fragile quality. I sensed it was a “pseudomaturity” that was not rooted intrapsychically. My own countertransference began to arise around his resistance or inability to integrate information, stating he had “heard all of this” during his previous treatment episodes. This knowledge of 12-Step recovery and psychological underpinnings, however, did not translate into behavioral or cognitive changes and remained isolated in an intellectual silo.

The staff that interacted with him daily had their own set of reactions to Roger’s pseudomaturity, primarily defaulting to treating him like an adult client and focusing on self-actualization in the service of independence. They encouraged him to make decisions about his discharge plan that were in direct conflict with his age and ability to execute. Shelly and David initially met this approach with gratitude, expressing their appreciation of staff’s ability to support their son.

They began to develop resistance to this stance of the recovery staff, however, as they evolved their own leanings toward discharge preferences. I could see their difficulty in expressing their leanings directly, preferring instead to wish that Roger would choose their private plan as an independent adult

I felt their ambivalence to directly express their parental needs and desires to their son. Shelly and David frequently deferred difficult conversations to me, placing me in the position of messenger. In spite of my encouragement for them to find their own voices in treatment, they seemed paralyzed by their fear that if they took a stance with their son they would invoke his rage and precipitate his rejection of treatment.

The family therapy was hence initially very tenuous, and Shelly and David seemed reluctant to allow us in to the issues in their family system. They seemed afraid of expressing themselves to their “adult” son. Most of the conversation was kept at the surface level, ostensibly to keep Roger from reacting in anger. They frequently deferred to Roger in therapy, allowing him to dictate the subject matter and to decide when a particular subject was off-limits.

Over time, it became evident that their inability to speak directly was causing Roger significant agitation. He repeatedly asked them for direct answers to specific questions, such as duration of treatment, discharge plan, and a potential family move. Their difficulty answering helped us see a fundamental conflict in their interaction with their pseudomature son: They wanted to address his density of problems with learning, academic status, peer relationships, and life threatening substance use, but at the same time wished him to be an adult, past all these problems and ready to function autonomously in the world. Pseudomaturity seemed to work for everyone, and cracking the shell was met with resistance—outrage by Roger and paralysis by his parents.

I noticed that Shelly and David took copious notes during the family therapy sessions, psychoeducational courses, and multi-family process groups. At one point Roger questioned the reasoning behind the note taking and asked me, “Do you think they even read what they wrote?” As my treatment relationship with the family deepened, it was revealed that David, who was an Ivy League graduate, suffered from the same auditory processing disorder as Roger. David compensated for this through his use of note taking, which may have served more to manage anxiety than to create references. Shelly also had significant cognitive distortions, particularly around the anger that she perceived Roger to be incubating. She had difficulty seeing that Roger was fundamentally angry at his parents’ inability to make decisions or have definitive dialogue, which risked cracking the pseudomature shell.

My family therapy work with Shelly and David became increasingly frustrating on a countertransference level, due in large response to their inability to make a decision about discharge planning. They were unwilling to commit to aftercare decisions because they perceived that Roger had to choose his own plan to comply. I began to see how Roger’s pseudomaturity became solidified in direct response to Shelly and David’s own need for maintaining it.

From a treatment perspective, this relational dynamic helped enhance the formulation and the treatment interventions that followed. Shelly and David, in their inability to assert their role as parents/leaders in the family, frequently deferred to Roger’s desires regarding discharge planning and treatment. Roger became increasingly agitated toward his parents as his questioning of transition plans and future goals was met with equivocal responses. We consolidated our formulation in treatment planning, now organizing our team around the problem of psuedomaturity within the family system.

This helped prepare me for interactions in the moment with Roger and his family. In one particularly poignant session, Roger asked, “Am I going to have to stay in treatment longer and do I have a choice in the matter?” I responded spontaneously, in an uncharacteristically direct and authoritative manner, by saying “Yes, you’re staying longer; no, you don’t have a say in the matter.” He became visibly relieved, and relaxed immediately, responding simply, “Thank you.”

It appeared that a direct answer to a direct question was comforting, as it had not been his experience within his own family system. In essence, Roger asked to be parented by me. By my responding to him in an age-appropriate manner, rather than engaging or reinforcing his pseudomaturity, he was able to experience the relief that came from the containment by the direct response.

I experienced this moment as a pivotal turning point, as I was able to observe the shift in Roger from agitated “adult” client in need of dictated treatment to an adolescent boy relieved to know what the next steps would be. I brought this personal experience to the treatment team as data to incorporate into the case formulation. We collectively paused and re-calibrated our understanding of each of our points of contact with Roger and his family.

Paradoxically, as Roger began to demonstrate increased maturity and personal agency through his recovery, Shelly and David appeared to unravel and become less mature. David showed increasing outbursts of anger and frustration, particularly in his email exchanges with me. He began to use profanity in a way that was incongruous with his normal presentation. He also had a flare up of rosacea, which seemed coincidental with his increasing internal frustration and distress.

David increasingly demonstrated resentment toward Roger, feeling that his addiction and associated behavior had dominated the entire family. This contrasted with the initial presentation, where the family had been willing to make whatever accommodations necessary to support Roger’s recovery. Shelly and David also became increasingly resentful that Roger, when given several choices for discharge locations, would not choose the facility that they preferred. This was confusing and frustrating for Roger, as he had difficulty navigating his own desires, much less the unconscious desires of his parents.

I brought my relational experiences to the treatment team, who could use them as data, even if it was encoded in the private language of 12-Step, psychiatry, or psychology. This lent organization and cohesion to our collective formulation. We could then organize a discharge plan to a long-term structured treatment setting where Roger could remain sober and begin to address the multiple deficits in his development.

Once the discharge plan was established and a therapeutic boarding school was chosen, there was a marked shift in Roger. He became more comfortable with being age appropriate and hence seemed more mature and grounded in himself. He was able to speak calmly and intelligently, and advocated for his needs in a way that he had not been able to previously.

Conversely, Shelly and David became increasingly fragile as discharge loomed. They made an unconscious attempt to undo Roger’s progress by suggesting a week-long vacation in California as a transition between programs. It was striking to feel their discomfort with Roger in his newfound actual maturity versus his previous pseudomaturity.

We could now understand how the pseudomature construct was failing everyone. The parents were unable to address their real child and Roger was unable to experience the safety of childhood containment from his parents. This fundamental understanding became the core of our multidisciplinary treatment team formulation, enabling us to incorporate 12-Step, medical (psychiatric), and psychological perspectives in our work with Roger and his parents.

The success of the case was not only in helping Roger mature; it was also in achieving an organized plan that the presenting construct of pseudomaturity precluded: Roger accepted a developmentally appropriate discharge placement and his parents took more responsibility for administering it.

The treatment team continues to discuss our experience of Roger and his family. Perhaps each subgroup uses private internal language; however, we can all refer to our collectively evolved formulation of pseudomaturity as we get updates from his current treatment setting and apply this to our formulation. This permits us to add to or revise our ongoing understanding of his maturation and his overall progress through recovery. We can then question our past interventions and modify our future predictions.

This case exemplifies our use of case formulation to integrate the 12-Step, psychiatric, and psychological components of our own multidisciplinary treatment team at Muir Wood Adolescent and Family Services. Specific aspects of this case have relevance to other cases, which aids subsequent formulations. But more importantly, the process of building a case formulation as a team carries our commitment to integration into our approach to subsequent cases. We see a meta effect of each case formulation enhancing subsequent formulations by virtue of both content and process. We seek to keep our experience of treatment, not just the information gleaned from it, out of the rigidity of silos, and integrated into a more cohesive clinical application.


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