6/9/13 In Defense of Addicts (Originally published on Psyched in San Francisco, by Andrew Sussman)
And really substance users and abusers as well.. Just last night I was in consultation with another therapist. Knowing that I specialize in working with clients struggling with drugs and alcohol he made the comment, "It must be difficult working with addicts as they're so unreliable." I asked if he could clarify and he further described his opinion that addicts are hard clients as they have problems with relationships, use substances to avoid feelings and situations, lie and he expected that most of my clients expressed such behavior regularly. When I asked what he meant by "addicts" it was clear that there was no differentiation with those that use or abuse drugs and alcohol and clients that may be physically and or psychologically dependent.
I found myself feeling frustrated and tried to explain that he was referring to a wide array of problems and clients that I have not found to be particularly unreliable. Sure, I have instances where my clients were using heavily or for some other reason, testing our treatment relationship. In my experience this can happen with any client and can be a useful part of our work. This colleague is also someone that refers most of his substance using clients to me and doesn't have the experience nor interest in working with this population as I do. In many respects I consider him a solid, experienced and insightful clinician. The conversation went on for some time and as a result I wanted to share some reflections.
- Therapists tend to specialize these days and even highly trained reputable therapists may have little to no training in substance abuse, use and addiction.
- Arriving at an agreed upon definition of addiction has not been easy for any of us. It is something that the Diagnostic and Statistical Manual of Mental Disorders (D.S.M.), psychotherapists and science in general has struggled with. When one entity or individual has a definition or model, it is tempting to assume they have also arrived at the truth and the correct model (Shaffer, 1994).
-Clients that use substances to varying degree are often clumped together and labeled as addicts. There is a widespread simplistic, all or nothing view towards drug and alcohol users that tends to objectify them. In my opinion this can miss the diversity, strengths and actual degree of substance problems with each client.
-From my extensive experience working with drug and alcohol users in private practice and several treatment programs I have not found this population to more unreliable or uncommitted to treatment than other clients. Clinicians sometimes experience what they might call "resistance" with this population. I think the difficulty may be the expectation that such clients commit to the clinicians and treatment programs' goals (generally immediate abstinence) rather than co-creating mutually agreeable goals that can be revisited together in treatment.
-12 step programs continue to be enormously helpful for many drug and alcohol users. They provide much needed support, structure, and spirituality for people worldwide. The A.A. teaching that all addicts are the same may help some stay sober when in the throes of craving and rationalizations, but like any teaching, it never applies to everyone.
Over the years I have worked with many clients whose differentiation from "all addicts" was pivotal in their treatment and in finding a relationship with substances that worked for them. In my practice I have found that sometimes we determine the relationship to substances is complete abstinence, sometimes moderated use and often it evolves. I have found that coming to know the meaning and utility of the substance use is often an important aspect of the therapy.
Andrew Tartasky, (2002) a harm reduction psychotherapist in New York points out that substance use problems come from a variety of sources, psychological, social and biological and that these are unique to each individual. He stresses the importance of understanding this with each client for treatment to be successful.
-Questions regarding meaning and utility of using substances and addiction in the field of psychotherapy can go back to Freud. Johnson reports that the father of psychotherapy was "ostentatiously and lasciviously addicted" (Johnson, 2003, p. 3), idealized cocaine and nicotine, and refused to give them up eventually leading to his death from nicotine.
Freud's fascination with cocaine was expressed in his letters to his fiancée Martha Bernays in 1884, "In my last severe depression I took coca again and a small dose lifted me to the heights in a wonderful fashion. I am just now busy collecting the literature for a song of praise to this magical substance." (Byck, 1974, p. 10-11). He refers to cocaine and a host of other substances regarding its help with his social anxiety in his letters to Martha in 1886 as he wrote, "I was quite calm with the help of a small dose of cocaine…and accepted a cup of coffee from Mme. Charcot; later on I drank beer, smoked like a chimney, and felt very much at ease without the slightest mishap occurring." (Byck, 1974, p. 164-165). It's easy to understand the field's discomfort with how best to take on drug and alcohol use considering Freud's relationship to them.
Perhaps my reflections here lead to more questions than answers. There's no one panacea for substance use problems or human suffering and I think that's a good thing. It leaves the door open for finding our own path and types of therapy that are a good match for our clients and us. Definitions of substance use, abuse and addiction need to evolve alongside therapies that meet clients' actual goals. This diversity also fosters continued creativity and learning.