Psychological principles of addiction and its treatment
Ever wonder where does addiction come from? Why can’t addicts stop? While the brain and drug abuse may be connected, some addicts are compelled to use drugs to cope with early life development problems. Here, Dr. David H. Jacobs delves into how addiction matches our early developmental needs. Plus, he shares with us principles that addiction professionals need to consider during the treatment of chemical addictions or compulsive behaviors.
Addiction: It ‘almost works’ as a coping mechanism
I recently read a very cogent comment about addiction by the physician who began a fasting/group therapy program at Kaiser Permanente:
It is hard to give up something that almost works.
He was talking specifically about food as an addiction but at the same time, he was talking about all addictions. Hard to give up something that almost works. A person I know who did very well in the fasting/group therapy part of the Kaiser program told me that 20 people started the program in her group and after 6 months 3 remained. A good indication of how difficult giving up an entrenched addiction is.
I would add it’s hard to give up something that seems like the only practical option. Sure, an addictive substance or activity has drawbacks (no one fails to be painfully aware of this), but there isn’t anything else that can be done, practically speaking, that brings about the same benefits as the addictive substance or activity. That’s more than obvious to the addict. Other people can make suggestions.
“You can do this…”
“You can do that…”
but the suggestions seem ludicrous to the addict. Oh yeah, instead of using I can go to a meeting and listen to pathetic stories from pathetic wretches, that will soothe me, calm me down, make me feel better, and so on. Uh,huh. I’m on my way.
Development psychology and addiction treatment
We all begin life and spend our formative years in circumstances not of our own choosing. We cope and adapt as best we can. The point and goal of adaptations growing up is emotional survival. Later on in life there is much more autonomy and freedom to act, but the traits developed during the course of growing up that enabled emotional survival are not easily thrown off, to say the least.
Such traits are the bedrock of the person’s psychic life and sense of what is real. They can be intellectually disavowed or challenged as an adult, but they persist all the same. They are as difficult to negate as the mother tongue because they are the mother tongue. The therapist must keep in mind that the traits acquired during the course of growing up were in the service of survival because failing to keep it in mind can lead to counterproductive attitudes towards the client.
Developmentally, how you feel about yourself and other basic feelings and convictions derive from how you were actually treated while you were acquiring basic feelings about yourself and what you can expect from other people. Self-esteem does not come out of thin air; it comes from being treated with esteem during the fluid period growing up in which self-regarding attitudes are formed. Achievements and accomplishments later in life have little effect on basic self-regarding attitudes, although people hope and assume this is not the case.
Psychotherapy aims at repairing basic feelings towards one’s self and others. Psychotherapy is the only activity (or at least one of the very few activities) one encounters in life whose purpose is to address and repair basic self and other regarding feelings.
An addictions therapist must work with a client’s actual fears, personal convictions, beliefs, and so on. There is nothing to be gained and much to be lost by imploring a client to have beliefs and inclinations he/she does not actually have. It is imperative that a therapist keep in mind that the client’s dispositions, traits, ways of coping, etc. are honestly come by. By “honestly come by” I mean that the addicted person’s pre-addict history (growing up) required adaptations that in the long run rendered addiction attractive.
Why addicts do not seek help on their own
As a therapist I meet addicts when they find their way to my office. As I have said elsewhere, a person with an addiction problem typically winds up in my office in large part due to pressure exerted by other people. This includes employers, attorneys, and courts, as well as the obvious source: family members. I’m hard pressed to think of a single addict-client I have seen who decided to come to therapy on his/her own, strictly speaking. This somewhat separates addicts in therapy from non-addicted clients, who frequently seek therapy on their own due to persistent personal distress.
Why is this? The addicted person does not usually seek therapy on his/her own because
(a) Although the addiction is clearly seen as a lot of trouble, the addictive substance or activity is the only way the addict knows how to get or can envision getting the benefits provided by the addiction.
(b) Seeking help is not something the addicted person is inclined to do as it only exacerbates feelings of distrust in others, a core feature of why the addicted person is addicted in the first place. The addicted person trusts the substance or activity, not people.
Why don’t addicts change on their own?
The natural consequences of addiction (social, physical, etc.) are insufficient to induce change. This is because the addiction is both solace and reward for the troubles caused by the addiction itself. In general, negative consequences do not bring about change for the better in a person’s basic traits and dispositions. If negative consequences altered a person’s way of being, then people would naturally change for the better as they got older and there would be no need for psychotherapy.
Rather, negative consequences tend to embitter a person and reinforce the traits and dispositions that led to addiction in the first place. If negative consequences pile up sufficiently a person may at least intellectually entertain the desirability of change. But changing the relevant driving feelings and beliefs by yourself is something like trying to get a good look at your face without the benefit of a mirror or some reflecting surface. Left to your own devices you only know what you know, feel what you feel, and so on.
What is the goal of therapy for addictions?
One important way to think about the goal of therapy is that of undoing or at least softening the damage done by maltreatment (even if unintended) during the formative years of growing up. This is the deliberate, professional task of therapy. It is not the deliberate, accepted task of any other kind of relationship. The injuries of the past cannot be remedied if the client feels the need to be hidden. The therapist must create an atmosphere in which it is safe to come out.
How long should addiction treatment usually last?
Feeling safe does not occur quickly. This is bad news for the amount of time that therapy usually takes and bad news for whoever party is paying for treatment, but it is reality none the less. The right time frame to think about the benefits of therapy is the client’s life time and how it will unfold if there is no therapy. No one wants to hear that deep-seated, fundamental personal issues cannot be fixed quickly, but that is the unfortunate reality.
Two main principles of psychotherapy in addiction treatment
1. Addiction treatment must be safe for the addict in order to enable truthfulness. Total confidentiality is imperative.
The therapist encounters a good deal of secretiveness and (I can’t think of a kinder word) lying in addict-clients. This goes along with the addict-client’s continued interest in the addictive substance or activity and perhaps surreptitious use. One of my all-time favorite writers, the anthropologist Jules Henry (1904-1969), once remarked that truth comes out as an act of courage or when there is nothing to fear.
In virtually all interpersonal interactions and social situations, truth is spoken very judiciously and selectively. There can be substantial negative consequences that derive from saying things the addressee does not like. Most people acquire a very political attitude towards candor and use it sparingly. Of course, there is a difference between white lies and black lies that should not be overlooked.
However, if one of the conditions under which the truth comes out is that there is nothing to fear, then the therapist is obliged to demonstrate that there is nothing to fear. It is impossible to demonstrate this if total confidentiality is lacking. Even if there is total confidentiality, therapy must ameliorate a basic fear acquired in the course of growing up: the fear of censure, negative reaction, loss of face, exposure to disapproval and contempt, etc. Everyone acquires such fears to some degree; people who have grown up in circumstances in which the balance between favorable attitudes and reactions and unfavorable attitudes and reactions on the part of caregivers was strongly lopsided in the wrong direction acquire correspondingly lopsided (negative) expectations about people. Addiction is a strategy to avoid having to depend on the good will, good intentions, etc. of people because addiction to an important degree takes the place of relationships with people.
2. Addiction is a substitute for acceptance and care that were absent during developmental stages. Addiction professionals must take genuine interest in an addict’s life and accept behaviors without condemnation.
The only way that the therapist can demonstrate that there is really less to fear from honest disclosure than the addict-client assumes is if the therapist genuinely has an unconditional attitude of interest and acceptance in what the addict-client says, feels, and does. This does not mean that the therapist is indifferent to the negative effects of use; it means that the therapist is genuinely interested in the addict-client’s inner life and its outward manifestations without condemnation. No “interested party” in the addict-client’s life other than the therapist can maintain such an attitude.
The therapist cannot directly alter what the addict-client does in the world outside the therapy office. The therapist can only concentrate on trying to make the therapy hour a period of time in which the addict-client encounters the kind of respect and interest that was in such short supply growing up. Rational argument has no impact on addiction, or on any deep-seated belief for that matter. What matters is direct experience. What matters is the therapist’s non-contingent interest in an acceptance of the addict-client’s inner life and personal struggles. This is the only thing that can compete with the addict’s interest in the addiction because the addiction is a substitute for the absent acceptance and care growing up. The therapist is in a position to provide it because the therapist knows what needs to be done and is not him/herself in a position to be personally disappointed by the addict-client. This is the up-side of professional training and acting within the confines of a professional role. The down side, to be avoided at all costs, is a disparaging know-it-all-ism that is itself harmful.
Photo credit: U.S. Department of Energy