18 May 2020

Personifying Addiction: Can Viewing One’s SUD as a Toxic Relationship Aid Treatment?

Who does this sound like?

·       Has a sense of entitlement and require constant, excessive admiration
·       Exaggerates achievements and talents
·       Is preoccupied with fantasies about success, power, brilliance, beauty or the perfect mate
·       Expects special favors and unquestioning compliance with their expectations
·       Never takes responsibility, blaming others for mistakes, oversights, or poor judgment
·       Has an inability or unwillingness to recognize the needs and feelings of others
·       Behaves in an arrogant or haughty manner, coming across as conceited, boastful and pretentious[1]
No, I am not referring to a contemporary politician—that is grist for another discussion mill. I refer to Al K. Hall, to Mary Juanna, to C.O. Cain, to Ox E. Contin, to Herr O’Wynn, to P.K. O’Cette…you get my drift. A personification of a substance use disorder, A.K.A. “addiction,” as some malevolent other that possesses an individual is not new. Robert Louis Stevenson’s famous The Strange Case of Dr. Jekyll and Mr. Hyde is semi-autobiographical in which the transformation of Dr. Jekyll when consuming the potion made of a “fine white power” to the murderous Mr. Hyde has become a familiar euphemism for addiction[2].
Although my personifications of a substance use disorder (SUD) may seem silly when compared with Stevenson’s more literary heavy, an important point remains: when characterizing addiction as a malevolent being, doing battle with that anthropomorphized image of an identifiable villain becomes more plausible than attempting to challenge some nebulous disorder. To view addiction as simply a social construction of inappropriate or otherwise described deviant behavior leaves the individual with that disorder little choice but to view the self as at best somehow defective if not a failure as a human being. Likewise, not only do those with an SUD tend to then label themselves as addicted with all that pejorative term implies, historically those who have attempted to provide treatment have tended to treat the addiction rather than the individual with the disorder.
Although interventions with the personification of an SUD may seem logical—who wouldn’t seek to confront the villain in any drama—when the addiction and the individual who has that disorder are indistinguishable in the eyes of the practitioner, such interventions become confrontational with the individual the focus of the practitioner’s assault. As William Miller suggests, this is when practitioners wrestle with their clients rather than attempt to dance with them. When confronted most individuals with an SUD will react instinctively, defensively recoiling from the practitioner whose treatment is perceived as a threat.
Interestingly, there may be two strategies that when employed in tandem may help avoid such
confrontations. The first is a given and has become quite well known over the last 30-years and for that reason not discussed in detail here; motivational enhancement therapy where empathy, collaboration, an appreciation of client autonomy, and evoking change talk are the hallmarks of effective treatment. The second is as yet unknown and argued in this essay as the personification of an SUD as an entity with which the addicted individual has a toxic relationship.
This “entity” manifests many if not all the characteristics of narcissism as outlined in the introduction above. As difficult as treating SUDs may be, inviting individuals to understand their dependency as a conflict with a self-absorbed parasitic nemesis can free one’s client to begin viewing change as a battle that can be won as opposed to a disorder that must be endured. Likewise, framing treatment as a struggle between the individual with the disorder and the personified disorder enables the practitioner to assume the role of mentor, guide, strategist, or counselor but definitely not the client’s adversary.
When seeing clients with SUDs I would often ask them to imaging their disorder as a gremlin sitting on their shoulder, constantly whispering in their ears, saying whatever was necessary to justify taking the next drink or pill or “hit.” I would then ask that they write a letter to their gremlin and tell it everything they ever wanted to say to get it to “shut up.” Once written, I would ask that the letter be read in group and for the group to comment and provide feedback, the point being that the personification of substance use dependence was a bully and that bullies can be silenced but only when confronted and when the one doing the confronting is supported by peers who understand how difficult the bully is to overcome.

What do you think?
To read how Dracula is an allegory for alcoholism/addiction, consider my essay Al K. Hall as Dracula: Film as a Clinical/Pedagogical Device[3]

[2] See Wright, Daniel. “The Prisonhouse of My Disposition’: A Study of the Psychology of Addiction in Dr. Jekyll and Mr. Hyde.” Studies in the Novel. 26.3 (1994): 254–267.

[3] If the link fails, the essay’s URL is https://robertchapman.blogspot.com/2012/07/alk.html

29 March 2020

Bloom Where You're Planted

"Bloom where you're planted"
Taken by Josh Chapman
For those of us 75 or younger, this time of pandemic may well be the most challenging time in our country that we have ever had to face. True, we have all experienced tragedy and heartache and rare is it when any have yet to experience doubt and fear in our lives. But even in those dark and challenging personal times, it was likely that there was always someone close or at least available to listen, to comfort, and to understand what we were going through and as a result, proffer the support needed to take that proverbial “deep breath” emotionally needed to calm ourselves and, as the old saying goes, “keep on keeping on.”

Unfortunately, when everyone is experiencing the same tragedy and heartache, is feeling the same cold, clammy fingers of doubt and fear encircle their very being, that “someone” close who is available to listen, to comfort, to understand is hard to find. It is as if the fictional Dementors so familiar to Harry Potter fans have somehow materialized and descended upon us, ready to suck the goodness and happiness and confidence from each of us…where is that Patronus charm when it is really needed.

Although there are no real Dementors nor Patronus charm for that matter, there may be something that can help quiet some of the doubt and fear that many…dare I say “all”…of us are experiencing, something in addition to prayer and faith in a Higher Power…music and its lyrics. Winston Churchill said during the Second World War that when going through Hell…keep on going. A contemporary singer-songwriter, David Wilcox, has committed that sentiment to a song. You can listen by clicking the title and the lyrics are below should you wish to follow along...and share a link to your songs of hope in the comments section.

You say you see no hope
You say you see no reason we should dream
That the world would ever change
You’re saying love is foolish to believe
And they'll always be some crazy
With an army or a knife
To wake you from your daydream
Put the fear back in your life

If someone wrote a play
To just to glorify what's stronger than hate
Would they not arrange the stage
To look as if the hero came too late?
He's almost in defeat
It's looking like the evil side will win
So on the edge of every seat
From the moment that the whole thing begins
It is love who mixed the mortar
And it's love who stacked these stones
And it's love who made the stage here
Although it looks like we're alone
In this scene, set in shadows,
Like the night is here to stay
There is evil cast around us
But it's love that wrote the play
For in this darkness love can show the way

Now the stage is set
You feel your own heart beating in your chest
This life's not over yet
So we get up on our feet and do our best
We play against the fear
We play against the reasons not to try
We're playing for the tears
Burning in the happy angel's eyes

For it's love who mixed the mortar
And it's love who stacked these stones
And it's love who made the stage here
Though it looks like we're alone
In this scene, set in shadows,
Like the night is here to stay
There is evil cast around us
But it's love that wrote the play
For in this darkness love will show the way
Show the way
Show the way

Source: LyricFind
Songwriters: David Patrick Wilcox
Show the Way lyrics © Universal Music Publishing Group

30 January 2020

Reframing the Abstinence Violation Effect

Long-term recovery from a substance use disorder (SUD) is difficult to define. Some suggest that although recovery begins with the decision to change one’s use behavior, others suggest that it cannot commence until and unless one’s “change in use behavior” includes total abstinence. Still others argue that one never recovers from a SUD and remains in a perpetual stage of “recovering,” but only if abstinence is maintained.

Be that as it may, a perennial threat to recovering, especially if abstinence is perceived as the prerequisite of changing one’s substance using behavior, is to use, even once. This use, however, small or infrequent, is viewed as having “botched” one’s efforts to change and is referred to in many ways—a relapse, a slip, falling-off-the-wagon, etc.—but no matter the nomenclature it is all but certainly accompanied by a personal sense of having failed. In formal treatment circles, this sense of failure is referred to as the abstinence violation effect or AVE and is perhaps the single greatest contributor to a return to active involvement in one’s SUD. 

Faced with working with individuals trying to change who tend to see use as tantamount to having “F-ed up,” practitioners who treat SUDs routinely are charged with helping them reframe such use as something other than “failure” lest they return to active use. Practitioners accomplish this in various ways, however, all necessitate helping these individuals to view their use as something other than personal failure and indicative of the absence of willpower, moral turpitude, or somehow evidence that recovery is beyond one’s grasp.

Reframing use as something other than failure requires a change in perspective. Just as a patient would rather hear a surgeon discuss a 90% chance of success in a procedure rather than a 10% chance of failure, those treating individuals with a SUD who use can discuss the opportunity the “lapse” presents to recognize previously hidden risks and high-risk triggers that can sabotage recovery. Referring to use following a period of abstinence as a “lapse” rather than having “F-ed up” presents individuals with the opportunity to “act on” their use rather than “react to” it. In addition to reframing, it is also helpful to invite individuals to appreciate the temporal nature of such experiences.

Substance dependent individuals and practitioners alike recognize the risk that urges to use and the triggers associated with them can play in sabotaging a treatment plan. What is often overlooked, however, is the time that elapses between these triggers and urges and the action taken or reaction that one has in response to them. It is this time between the onset of the urge to use and the decision one makes to use or not use that presents the opportunity for the substance-dependent individual to “do something,” the result of which is to move closer to or farther away from use.

The space separating the “urges” and “triggers” from the decision to “use” or “not use” is representative of the “time” that exists between these two phenomena. Depending upon individual circumstances, the precise amount of time separating these as two poles can be minutes or days but irrespective of the specific amount of time, the fact that this separation can be measured in time presents the individual with the realization of an opportunity to do something…if you will, to act rather than react. As a matter of fact, one cannot not do something during this time as to do nothing is in itself to do something.

The individual who grasps the temporal nature of a lapse is presented with an opportunity to take the steps necessary to prevent it. Just as one can learn about how personal actions when using set oneself up for use, following this model, so can this individual appreciate the significance of having a plan in place to deal with urges and triggers should they occur…and most any recovering individual will tell you that it is not “if” these urges and triggers will occur but “when” they will. NOTE: The list of things that can be done during this time is essentially limitless. Exploring “proactive” steps to avoid use and/or cope with urges to use becomes an important topic for discussion with one’s treatment specialist or sponsor.

Alcoholics Anonymous has a slogan that speaks to the importance of being prepared; change people, places, and things. Preparing to avoid the expected triggers that can initiate an urge to drink will increase the likelihood of avoiding lapses. In addition, should use occur, viewing it as a lapse rather than a failure—not to mention an opportunity to learn something new about preventing potential future risks to recovery—increases the likelihood of maintaining sobriety.

Wayne Dyer once wrote that the only difference between a flower and a weed is a judgment. Now, apply this reasoning to one’s use after a period of abstinence: the only difference between a lapse and a failure is _____.

What do you think?
Dr. Robert

Thank you to Jessica Williams of IRETA whose blog post "Combatting the Abstinence Violation Effect" prompted the thinking that resulted in this essay.

30 November 2019

Motivation – finding a reason for change

Whether you think you can or think you can’t, you are right.
Henry Ford

It does not matter how slow you go as long as you do not stop

We are all familiar with the adage, you can lead a horse to water, but can’t make it drink. Although the first phrase in this proverb may be true, the second only applies because it presumes that change is something motivated by an intervention attempted by an outside force. If, however, we abandon that premise and consider change an “inside job” resulting from internal motivation, then a 21st Century version of this adage may well be, You can lead a horse to water but can’t make it drink...but you can salt the oats.
This “salting of oats,” although accomplished by an “outside force” is nonetheless intended to evoke—although sometimes provoke—an internal shift in perspective. It is this shift that enables those being interviewed to evaluate their situation differently, to view the facts in their life through a “new set of lenses” so to speak. Like the teacher who asks a class if two-minutes is a short or long period of time and then responds, smiling, to a pupil who blurts out Short, Okay…then hold your breath for two-minutes, a shift in perspective can affect one’s interpretation of the facts, which becomes a precursor to a change in behavior. A humorous allegory to illustrate:

Lipstick in school

According to a news report, a certain private school in Washington was recently faced with a unique problem.
A number of 12-year-old girls were beginning to use lipstick and would put it on in the bathroom. That was fine, but after they put on their lipstick, they would press their lips to the mirror leaving dozens of little lip prints.
Every night the maintenance man would remove the lip prints, and the next day the girls would put them back.
Finally, the principal decided that something had to be done. She called all the girls to the bathroom and met them there with the maintenance man. She explained that all these lip prints were causing a major problem for the custodian who had to clean the mirrors every night (you can just imagine the yawns from the little princesses).
To demonstrate how difficult it had been to clean the mirrors, she asked the maintenance man to show the girls how much effort was required.
He took out a long-handled squeegee, dipped it in the toilet, and cleaned the mirror with it. Since then, there have been no lip prints on the mirror.
There are teachers...and then there are educators.

Reflecting on this, one might argue, there are interrogators…and then there are interviewers.

The less ready one is to change, the less motivation there is to make a change. Effective interviewers know this and resist the temptation to engage in what William Miller (2013) refers to as the “righting reflex” (p10) or an attempt to provoke change in the belief that doing so prevents additional untoward consequences resulting from the maladaptive behavior. However, as the old saying goes, right church…wrong pew. Instead, a more efficient approach to accessing an interviewee’s internal motivation is to assess where she or he may be on the continuum of readiness to change and then engaging the individual in such a way as to facilitate movement along that continuum toward change.
It may seem counterintuitive to delay interceding in one’s high-risk behavior, especially if that behavior presents the real potential for physical harm to the individual or those with whom she or he interacts. In fact, many who resist this approach to interviewing argue that a delay in confronting one’s reticence to change is tantamount to enabling the continuation of maladaptive behaviors. But consider this question: Which is the shorter total amount of time, the time between when someone is confronted prematurely about making a change and terminates treatment before returning a year later in a crisis, ready to consider that very change, or the three—or two or four—months it may take for a practitioner who recognizes the importance of moving through the stages of readiness until the point is reached where the individual chooses, of her or his own accord, to change? In short, as William Miller (2013) asks, is it more productive to wrestle with one’s interviewee or to dance?
Economists refer to something similar conducted by business executives and their chief financial officers as a “cost-benefit analysis.” When considering the costs involved in realizing a benefit, one can assess if the ratio between the costs associated with realizing the benefit(s) are such that they warrant continued “payment.” If the costs are deemed too high, exploring change becomes logical if not obvious. Facilitating this consideration of “costs vs. benefits” constitutes the “salt” added to the oats our interviewee is fed, thereby evoking a “thirst” for change.

What do you think?

[1] For a worksheet related to this essay, visit https://tinyurl.com/yxapk8ou
Miller, W. & Rollnick, S. (2013). Motivational Interviewing: Helping people change. Guilford Press: NY, NY