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]

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[1] Based on Mayo Clinic’s website’s “signs and symptoms” of Narcissistic Personality Disorder

[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

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.

Responding to Resistance

In the introduction to Chapter 8, "Responding to Resistance" (p. 98) of Miller & Rollnick's Motivational Interviewing, 2nd Edition (2002)--and please note that this is a text that addresses alcohol and other substance abuse specifically, but I sense that its principles are applicable across the counseling spectrum--the authors suggest that some practitioners view resistance to therapy as something inherent in the client's character if not indicative of a presenting problem such as alcohol or other drug dependence, symptomatic, if you will, of the disorder to be treated. They argue that attributing client resistance to an inherent personality characteristic may be something of an erroneous assumption. This may be particularly apropos if the counselor's perception of client resistance is viewed as a clinical defense mechanism and the denial of "the problem" that must be breached if therapy is to progress. Miller & Rollnick suggest instead that resistance, "...to a significant extent, arises from the interpersonal interaction between counselor and client."

I found this argument provocative in light of my long standing problem with the traditional, "kick in the front door" S.W.A.T. team approach to "confronting" client denial and "breaking down" resistance to treatment as the prerequisite to change for addicted clients. These clients, presenting in what Prochaska would refer to as a "precontemplative" stage of readiness to change, are likely to be steeled in their resolve to resist what they must see as "attack therapy" with treatment offered by counselors that seem to suggest that, "addiction is the problem" and "my way or the highway" is the answer. As early as 1973 Lieberman, Yalom, & Miles (Encounter Groups: First Facts, NY: Basic Books) suggested that confrontational group therapy was likely to result in more harmful and adverse outcomes in therapy than alternative approaches. If the first order of clinical business for a practicing counselor or therapist is to "do not harm," then avoiding an iatrogenic result of that counseling may be what Miller and Rollnick are addressing in their argument that resistance is a result of interpersonal dynamics in a session rather than client pathology.

My grandfather used to say that you do not remove a hornet's nest on the porch by beating it with a stick. I am wondering if this was not a layman's equivalent to Miller and Rollnick's argument suggesting that resistance arises more from the interaction between client and practitioner than the pathology of the client...the bees were likely not resisting until the first blow from the stick

You can read more on "Motivational Interviewing" and "Stages of Readiness to Change" at my website, http://www.robertchapman.net...click "Treating Addictions" in the menu

Robert J. Chapman, PhD

http://www.robertchapman.net
LinkedIn profile: http://www.linkedin.com/in/rjchapman