Like many counselors fresh out of school, I began my practice in the field of addiction where the rate of burnout for a therapist is high. Addiction counseling is demanding and the prospect of successful recovery can be discouraging. Most models of addiction intervention are supportive or behavioral and those young therapists interested in deeper work can find themselves particularly frustrated, as I did. However, I learned a great deal in those early days and that information shaped how I practice today.
Every addiction starts with a healthy intention. We enact rituals in an effort to soothe pain or conflicts, to squelch or fend off discomfort. But the anarchy of those actions over time is that they lead to meaningless behavior and forms of self-deprivation that have deeper consequence. What starts as a coping mechanism, a part-time way to deal with stress or sadness or to add fun to our lives becomes a full-time distraction. Rather than serving as one of many possible ways for coping with difficult feelings, an addiction becomes the primary one, sometimes the only one. What started as a solution becomes the problem, raining tyranny over our lives. This is what finally pushes dependent or abuse behavior into an addiction.
An addiction changes the way we act towards our own and others’ lives. Our behaviors grow increasingly inconsistent with our core values and beliefs. Our relationship to work, money, friends and family gradually change in the service of feeding behavior which now seems essential to our existence. Addiction develops a life of its own, taking control of us like a too demanding parent, spouse or lover. Activities which once brought joy, relief or relaxation fail to satisfy their former purpose. No longer a payoff for doing them, they quietly disappear from our daily repertoire.
Many “experts” believe that addiction is an incurable chronic disease. For them, recovery is a lifelong battle which requires attention and abstinence, one day at a time. There is no gray area in between life and addiction. If we are not in recovery, our lives are frozen stiff — we cannot by definition learn, change or produce anything of true meaning. Because we deny, bury or refuse to treat our illness, we are doomed to a life that will progressively deteriorate. Only active, ongoing intervention can save us.
Other experts don’t view addictions as so black and white. They believe the mind/body will naturally recover without intervention given the opportunity for an addiction to play itself out without shaming, repressing or external regulations.
Some experts question the concept of addiction altogether along with the authorities that determine them. For them, addictions are socially constructed, invented for the convenience of mental health professional who lack the sensitivity to understand the subtlety and nuances of so-called addictions and their potential creativity. These advocates for alternative approaches, blame the high rate of failure of treatment centers and the “one-solution-fits-all” model as the failure of the mental health profession and the pathologizing of the addict as an “other”; someone unlike ourself.
Where do I stand?
I have never had an addiction, at least not by common standards. I buy too many shoes and books, sometimes spending beyond my means. Shopping is a comfort, an escape, as well as an expression of my freedom, and the purchases I make serve as a form of both identification and creative self expression. I think that if someone told me I could no longer buy shoes or books, I would feel emotionally trapped or worse, suffocated. Still, my behavior is not an addiction. I have not accumulated debt I cannot hope to ever repay nor does my collection of shoes overtake my household (my partner might disagree with me here) or interfere with other meaningful aspects of my life.
In my years of working with gamblers at the start of my practice, I experienced many whose behavior was frightening, heartbreaking and self-destructive. I saw how hopeless a person could feel. And yet despite their despair, they chose to continue to hurt themselves and those who loved them. Why?
The answer is always for profoundly individual reasons. Yet I did not often have the time nor luxury — especially in those early days in a managed-care facility where each and every minute of my time with clients was expected to serve the purpose of getting them “fixed” and back out the door — to wait for the reasons to surface in therapy because many of these clients came to me in extreme crisis and needed, above all else, to mitigate damage and reduce or prevent further harm. And though I believe a person’s addictions are driven by their personal stories , I also believe that it is important to help clients tailor a behavioral program that will interrupt their self-defeating behavior(s) as quickly as possible. These two things go hand-in-hand, not one before the other; stop the behavior through boundaries and plans, and simultaneously build strong connections to other things and other people that can bring strength and joy. Every addiction is as different as the person who bears it. Therefore, my approach as a therapist is holistic — attacking the problem on multiple levels, drawing from several models of treatment: behavioral, psychodynamic, relational, existential and medical. I help create a set of interventions that are meaningful and relevant to the uniqueness of the case.
Of course , it is never easy to dislodge an addiction. It helps when a client has a support system of others who have been in their place, and I always recommend that a client I see struggling with addiction in individual therapy also attend a support group. Much can be gained from 12-step programs — many even believe that these programs have saved their lives. Together, we build a structure of support – a set of steps that will lead a client further and further away from the behavior that is dismantling and disabling her life. I encourage a “one day at a time” philosophy because it makes things manageable, palatable, in the face of an overwhelming circumstance. Regardless of whether or not it is true, most alcoholics cannot wrap their minds around a life in which they will never again have a drink.
At the same time as we are creating new structures and patterns, I ask clients to examine what they gain from their addiction. While most know all too well what their addiction has cost them, few have considered what they have gained for better and worse.
For alcoholics it can be a way to relax after work or loosen up in a social setting — to be what they perceive as more fun or interesting. For gamblers, it can facilitate the feeling of importance or familiarity, acceptance, when walking into a casino or poker club. For sex addicts it can be the thrill of being bad or the possibility of getting caught or finding a way to tap back into the youth and excitement of new sex. For my son, who may be close to having a video game addiction, it is the feeling of being powerful that is achieved through a sense of mastery and control.
The answer to this question is important because it pinpoints the feelings and experiences that a client will be giving up when she stops engaging in her addiction. For many, losing these things comes at a great price — one that may make life not feel worth living. For some, giving up an addiction represents the loss of a large part of our identity.
Finding our way out of an addiction requires broadening coping mechanisms for managing uncomfortable emotions. We will need to acquire new, healthier ways of creating the feelings, experience, or expression of parts of ourselves that were achieved by what eventually became our addictive behavior. Trying to fight an addiction by tackling only one component of it — the physical side such as complete withdrawal — is much less likely to result in long-term sobriety than by taking a more system-based approach that includes creating new rituals and routines as substitutes for those that have triggered addictive behavior in the past. Sometimes that involves breaking other dependences like smoking, overeating or debting which may put us in danger of relapsing by continuing to facilitate avoidance of the underlying discomfort. Under those circumstances, it is the pattern in which all self-defeating behavior is embedded that needs be disrupted. While it may be especially difficult to deal with these cross-addictions at once, for some it is the only way to create patterns that will support real change.
Recovery is rarely straight forward. Relapse is part of the process. While the idea of counting days of sobriety is useful for some, it can also lead to feelings of shame when a relapse inevitably occurs. Relapse may be a necessary part of moving forward, a respite from the intensity of change, a place to touch base with an old self and to examine its relevance, recommitting to change with greater certainty.
The road to well-being is as highly original as the paths that allow our lives to fall out of balance. I have worked with clients for whom complete abstinence restored them to “sanity” and others for whom a system of moderation and control achieved their goal. What works best for one client may be the worst approach for another. The long-range direction of therapy emerges instead, from an understanding of the uniqueness of each client’s past and present, their method of making successful life changes in the past, and the creativity of our interactions in therapy over time.