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The Importance of Meaning in Understanding and Addressing Problematic Drug and Alcohol Use
Is a guy who goes out several evenings after work with friends and often gets drunk sharing a meaningful social experience? Or is he killing time, zoned out to avoid dealing with the depressing emptiness of his life? Is a college student who uses speed to cram for a test just using it to stay up later to get more studying in? Or is she self-medicating ADD (Attention Deficit Disorder), or trying to make up for a semester of missed schoolwork because of paralyzing anxiety and insecurity about her intelligence? Is a successful executive who smokes high potency pot most evenings just relaxing with music after work? Or is he retreating to a private cocoon, safely insulated from a social world filled with anxiety, or sexual insecurity that often contribute to bouts of suicidal despair about the lack of intimacy in his life?
All of these people were patients of mine who appeared to be social recreational users, not evidencing any serious signs of abuse or dependency. For them, their substances of choice help in some way that is highly meaningful to them. They are used not only for the pleasure they provide but also to cope with painful feelings and life circumstances. These meanings and functions had to be clarified and addressed for them to successfully resolve their problem substance use.
Over a long career as a psychologist working with people with drug and alcohol problems, I have had an ever growing conviction that recreational drugs are never the real problem; instead, it is the multiple meanings and functions that drugs, their physiological effects and the rituals associated with them take on for the user that determine whether they become problematic or not. Just as with automobiles and video games, it is the reasons for using them and the way in which they are used that is at issue.
Thinking of the drug alone as the problem can reinforce a denial in the user and in society at large of the many factors that make drugs so desirable to some that they would risk everything. At the personal level, a disconnection from the reasons for using gives rise to the addictive process. Instead of feelings being about oneself, one’s needs, wishes, or suffering, the pain or struggles are expressed in the desire for the drug; the problem is put “in the drug”, not in me. If we consider that the personal and social meanings of substances determine why and how use patterns become problematic, we see that it is essential to identify and address the particular meanings that substances carry to bring about positive change. Each person has a unique set of meanings and feelings that they give to their own substances.
Most Americans experiment with drugs and alcohol. Some of these experimenters find the initial experience desirable enough in some way to want to repeat it. 15-30% of casual users go on to develop patterns of use that interfere with, threaten or damage some important aspect of their lives.
Why do some use safely and others develop serious life threatening problems? Drugs lead to dramatic and varied biochemical changes that result in shifts in body sensation and states of consciousness. These changes are not meaningful, pleasurable or desirable to all peop0le in the same ways. Many people experiment with drugs and don’t like the way they make them feel, or don’t like them enough to use them with their attendant risks. It is important to realize that the use of substances is experienced as desirable in relation to other aspects of one’s inner and outer life.
From this “bio-psycho-social” perspective, problematic substance use is understood to result from the interaction of personal meaning, socio-cultural, and biological factors that is unique for each individual. With chronic use, they may become increasingly relied upon for whatever functions they perform for each person – for example, interrupting the anxiety of dealing with intimacy, or sexual performance. Substance use can become intertwined with psychological functioning and lifestyle such that it becomes part of the fabric of the user’s experience and essential to psychic stability. It can be said that each user develops a highly personal relationship to drugs that reflects this complex interaction.
Katherine was a patient of mine with a history of early sexual abuse and a series of intensely humiliating experience related to a chronic illness in childhood. She used substantial amounts of alcohol and marijuana every day to keep herself in an emotionally numbed state and ward off intense feelings of shame, self-hate and suicidal depression. The initial work in therapy clarified the meaning and function of her use as protection against these painful issues. As this connection was made by Katherine in the safety of the therapy relationship she became more aware of these feelings and we were able address them in our work together. As Katherine became less self-critical and developed greater self-acceptance, she became more aware of her desire for an intimate relationship. These changes, in turn, led her to feel more conflicted about her substance use, more aware of its threat to her health and self-image and more motivated and able to reduce her use dramatically.
To best understand the problematic aspects of drug use, a clarification of the highly personal meanings and functions of the drug is essential. Since the true meanings and functions of the desire to use may be disguised from the user or out of awareness, this is often a central focus of psychotherapy. Whether in psychotherapy or on ones own, acknowledging that one’s relationship to substances is highly meaningful can open up many avenues of personal attention that can support the effort to develop a healthier relationship to drugs or alcohol.
Parts of this article were published in the New York Psychological Association's Psyche News, July 2008.
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What was your path to harm reduction psychotherapy and how would you describe the process?
I was trained in graduate school as a psychologist in a kind of integrative psychoanalytical perspective that honored the multiplicity of the different psychoanalytical perspectives as well as the value of cognitive-behavioral approaches. It was a way of thinking of human suffering and human problems in a very complex way that also showed the importance of individualizing any attempt to help people. I felt very lucky to be exposed to this kind of very interesting, diverse group of ideas. This was at the City College of New York Clinical Psychology program in the 1980s.
In the course of my training as a graduate student, I worked with some people who had problems with drugs and alcohol, but I never got any formal training in drug and alcohol counseling. Then, at an internship at King’s County Hospital in Brooklyn, I saw some patients that had some problems with drugs and alcohol. Again, I never really got any formal training but, in trying to think of how to work with these folks from within the perspective that I had been trained in graduate school, there was some success but also a lot of bumbling.
Later, by what appeared at the time to be by accident (in retrospect I don’t think it was completely by accident), I got my first job out of graduate school in a multi-modality treatment clinic up in East Harlem. There I got my first formal training – well, informal actually but real – in an addiction treatment approach that was really based on a kind of old-school addiction counseling mode that included 12-Step and was based in the disease model. I learned the whole paradigm that we’ve now come to describe as the “abstinence-only” model. Although I had been trained in a very different way, what I was being taught at the clinic (not that it was necessarily correct, mind you) in my entrance into the addiction field was that all of that complex psychological way of thinking was all well and good until it comes to trying to work with people with addiction problems: here’s this whole other model that is the only game in town and is the only one that really works. Again, this is what I was being told. So I learned that model somewhat uneasily. And I was left to try to reconcile these two apparently competing points of view.
Over the course of the next seven or eight years, I went on to develop and direct a few addiction treatment programs. I was the Clinical Director of one of the premier intensive outpatient programs in New York at the time. I was still working within this traditional paradigm; this was all in the late 1980s. We had some success and a lot of failure and we came to understand that, within the traditional framework, addiction is a very difficult disease or disorder to treat, that many folks are not ready for sobriety and that we were limited in what we could do – it was just the reality that we had to face up to. That never sat comfortably with me, I have to say, and, as the Clinical Director of this program, I was very interested in looking at outcomes and looking at our success. And over the course of the four years that I directed this program, it began to dawn on me with increasing clarity that we were failing to be of help to the overwhelming majority of the people that initially walked through our doors. It was like a dirty little secret that I was ashamed to admit to myself, let alone to anyone else. I was feeling kind of guilty - and ashamed and anxious and confused - and, ultimately, I came to feel that this was not an acceptable outcome for our treatment program and that the standard treatment model had to be challenged. We were blaming the patient for our lack of success rather than becoming curious about what might be wrong with the model and/or the treatment approach.
At this same time, I had the good fortune to start a private practice. In my private practice, I started getting calls from people who were actively using drugs and alcohol and who wanted therapy, but who were not necessarily clear about what they wanted to do about their drug use, or were certainly not ready to stop. Since they seemed to be good therapy candidates, I thought I would become more flexible and sort of see if I could work with them while they were actively using. I began to experiment with a kind of new approach that I think harkened back to my early training and to my continuing experiences of training and therapy and, lo and behold, many of the patients actually stayed in therapy. They were able to meaningfully engage; they began to address their drug use and their drug use began to reduce or in some cases stop; my clinical experience just didn’t fit with either the model that I had been taught back in East Harlem or at my then-current well-respected clinic. So these two experiences: 1) the failures of my treatment program and 2) my being able to be helpful to people who weren’t supposed to be treatable made it increasingly clear to me that there was another way.
I happened to have a relationship with Alan Marlatt (this was in about 1992), and I remember having a telephone conversation with him - me in New York and he in Seattle - and I said, “Alan, I’m having these treatment experiences with patients that I’m not supposed to be having: people are actually getting better in therapy!” And he said, “You’re doing harm reduction work.” I had never heard the term before. That was my introduction to the concept of harm reduction. Then Alan began to describe this concept as a kind of alternate paradigm, and it was as if the clouds parted and the sunlight shone through; suddenly everything began to make sense! It seemed to me that this new paradigm explained the failure of the traditional model and also explained why I was having success with my so-called untreatable patients. So, in 1992, my career took a 180 degree turn because harm reduction seemed to offer so much of value and benefit to everything that has to do with both understanding and being helpful to people struggling with addictions or having problems with substance use.
How I’ve come to understand harm reduction since then is that there’s a philosophy that’s embodied in harm reduction that we first learned about culturally through needle exchange. And this philosophy has certain fundamental principles that the handful of us who have been working as harm reduction psychotherapists have been applying in psychotherapy. These principles, I think, can be applied in different applications for different clinical populations. Essentially what they have to do with is really radical abandonment of a preconceived idea about who the client is, what the nature of the client’s problem is, what the client needs from you, and what you can offer that can be of help to that client. We’re challenged to put all of our own preconceptions aside and try to really understand what this person needs and wants and how we can be of help. It completely turns that traditional addiction treatment relationship on its head.Instead of coming in with a whole model about the nature of the addictive disease and what people need to do and the only way they can recover, we actually have to come in open and without seeing that kind of preconceived perspective of people as a kind of countertransference [Editor’s note: countertransference refers to a therapist's feelings about a client that originate from the therapist's own life experiences and issues] block that prevents us from being able to actually listen to patients.
What that suggests is that we need to listen to the patient and start from where the patient is motivated to seek help, which becomes the starting point of the treatment. And listening is the glue that strengthens or facilitates a strong therapeutic alliance, which is crucial in good treatment. Within that therapeutic alliance, we can then develop a collaborative relationship with people around the questions of what hurts, what’s harmful, what’s not working, what’s problematic and how they can begin to set meaningful personal goals in the direction of reducing what hurts or what’s harmful, and move in a more positive direction. This is the basis for the whole idea of small, incremental change: steps in the right direction. And what we see is that as people begin to reverse the negative spiral of addiction or problematic substance use and begin to make positive changes, a positive process of change gets set in motion. Small changes lead to other small changes as people begin to feel a little bit better. They feel more empowered and emboldened to take further steps in their lives, more confident about being able to change: like a wheel in motion, this change process gains momentum with each success.
As people begin to feel better, part of what’s fueling problematic substance abuse gets taken out of the equation and people’s relationship to the substance changes. They may now feel more conflicted about using in problematic ways. They’re more motivated to reduce their use or use in a safer way or to stop. They’re now increasing seeing that the important things in their lives, or values are now being threatened by excessive use. It’s about helping people to see more clearly what’s happening in their lives. If we think about the safe space of a harm reduction therapeutic context in which the therapist is non-judgmental, compassionate, accepting of all of the aspects of the person, we’re now inviting all of those aspects - their substance use, their reasons for using, their other interests in life, their aspirations that have been thwarted, their interest in health and growth – to fully come into the room, and now we can create a context that helps the individual grapple with the potential conflict or problems that their substance use may pose for their pursuit of these other interests. So now it would be possible to talk with people from the full experience of who they are, about whether, just maybe, there are other ways to resolve this ambivalence than continuing to do what they’ve been doing. It becomes possible, then, to think about new possible creative solutions, ways of resolving what is important to them in their lives including their drug use.
One of the things that continues to draw me to harm reduction is its focus on creativity, both for me and for my patients. And how within that creativity, free and open thinking is nurtured, leading both of us to experience a more positive encounter. I think that this creative thinking is also shown in our goal: to be maximally helpful to everyone who walks in our door. I acknowledge that I have limitations; each therapist does, and our limitations are going to frame to whom we can be helpful. Yet the more flexible, free, creative, and willing to be impacted by, molded by, and shaped by a client or our experience with the client - and draw upon whatever seems like it might be helpful - I think the more possibilities open up for how that therapy actually can be helpful.
This is why I think of myself as practicing integrative harm reduction psychotherapy because I wanted to integrate as much as we possibly can, or need to, into the services we provide. We need to be willing to give advice and make suggestions and talk about skills and strategies that might be valuable or useful to experiment with when that seems to be called for. Or, on the other hand, with some people, I need to be all about exploration and clarification, kind of keeping myself out of the way because that would be experienced by that particular patient as a kind of impingement or threat to their sense of autonomy. Other harm reductionists have a more doctrinaire way of doing harm reduction therapy, which I think runs the risk of becoming just what the old abstinence-only paradigm became: that is, the “‘there is only one way of recovering” kind of thinking. Some harm reductionists would say “well, we’re going to be only about empowerment and staying out of the client’s way, and we’re not going to give people what they need even when they’re completely out of control and need someone to step in and take charge because they can’t right at that moment.” An example of this is: what if your client was suddenly having a heart attack? You wouldn’t simply stand there and do nothing; that would be both unethical and non-humanistic. With substance abuse or other potentially dangerous behaviors, sometimes we have a similar obligation. The real challenge is to be able to use some combination of intellect and theory and intuition, dialogue, and negotiation to figure out with the client how they need for us to be in order for us to be most effective for them at this point in their lives. After all, we are service providers, and so we need to provide the service they want and need. Ultimately, we might need to be going in directions with our patients that we hadn’t anticipated before.
Harm reduction, as far as I’m concerned, embodies the key concept of moving in a positive direction. It values health and it values life, which is why, from my perspective, the person who is simply about empowering and destigmatizing the addict is not necessarily practicing real harm reduction - if that client is at risk to die or lose their kids or lose their job, then the therapist has a duty to intervene. When we see some clear and present danger that’s being imposed by somebody’s behavior, it seems to me a harm reduction framework would suggest that we somehow need to discuss it with our patient or intervene or attempt to engage the person in grappling with their risk in some way; we can’t simply ignore the risk.
Along with the values of destigmatizing and empowering is the value of understanding the other side of a client’s ambivalence, really understanding the reasons why they might still be using. Let me tell a story that I think will help to illustrate the different movements within harm reduction that I think are trying to co-exist or complement one another somehow. I think part of the struggle we’re having is because a lot of folks don’t come to harm reduction as I did - through a therapeutic door trying to help move clients in a positive direction and improve their quality of life or help them identify personal goals. Rather, a lot of people came into harm reduction as activists both to challenge the stigmatization of drug use and drug users that has contributed to inadequate health care for that population and to help us culturally to view the spread of HIV and AIDS and the incarceration of drug users, as prejudicial. So a) these folks don’t have clinical training and b) they have a different mission in a sense. Part of their job is to get “‘the man” off the drug users’ backs. I think most of us agree with this part of our job, but I don’t necessarily understand how that part of our job needs to be integrated with this other clinical agenda. So here’s the story:
I was supervising someone - this would be around the early 1990s I believe – a social worker, pretty well respected and working in a harm reduction center. He walked into the Day Room one day and Jose, a patient, was lying on a bench nodded out. The social worker looked at Jose and thought that he didn’t look very well. So he went up to the caseworker and said, “Hey, what’s up with Jose, he doesn’t look well.” The caseworker said, “Oh, Jose comes in every day; he just gets high and nods out. It’s kind of a safe space for him to chill. You know, just leave him alone; don’t mess up his high.” So the social worker said, “Hmm, okay, but he doesn’t really seem to be breathing very well. Have you checked in with him?” At this point, a few of the caseworkers started to get a little angry and said to the social worker, “Look, we know Jose and we’re telling you, just leave him alone. He comes in here everyday and this is just his safe space!” The social worker then started to get increasingly anxious. So he went up to Jose and bent down to listen to his breathing to see what was going on, and he noticed that Jose’s skin was pale. He thought to himself, “This man is overdosing!” And then said to everyone, “I think this guy is in serious critical condition. Would somebody call 911?” And the caseworkers started yelling at him to back off, so he went and called 911. The EMTs arrived in five or ten minutes and said if they had not arrived for another five or ten minutes, Jose would have been dead. So, here’s the punch line: who was practicing harm reduction in this scenario? I think they both were, but they need to find a way to live together - and certainly work together better - for the sake of the well being of the patient. This story is important to me because it showcases how we’re dealing with these broad, diverse groups of people who need different things – whether we’re talking about patients or therapists! So, from my point of view, harm reduction means adapting to meet the needs of different people.
Harm reduction psychotherapy also requires that we be both very skillful and very knowledgeable, which is one of the major shortcomings in the traditional drug and alcohol treatment field. And I should say this is true in the original harm reduction grassroots field as well. It is really a reflection of the stigmatization of drug users. That is, in this society we have decided that drug users, whether in harm reduction or traditional drug treatment, don’t need sophisticated help. They can benefit from untrained or poorly trained or para-professionally trained folks who have limited education, who care more than anybody and yet are generally quite limited in their knowledge and level of skill.
Instead, I think we’re arguing for, as harm reduction psychotherapists, the gold standard: harm reduction psychotherapists need to be highly skilled and highly educated and highly sophisticated and care more than anybody in order to bridge substance use issues with mental health issues along with the biopsychosocial issues that drug use reflects or is entwined with. So, we’re really arguing for elevating the entire field in a way.
Now, let me also say that I honor the tradition of self-help in AA and other 12-Step programs, of the therapeutic community movement, and of the grassroots harm reduction movement. All these movements evolved to meet the needs of people who were abandoned by the medical and psychiatric communities along with the rest of society. There’s something heroic and tremendously admirable about people stepping up to try to find ways to help one another to make up for this gap. But, then, as history moves on and now we have a whole treatment industry that is founded on being able to hire - to exploit - these folks and pay them poorly and train them poorly, now we’ve got an industry that has an investment in keeping things the way they are rather than upgrading the level of expectation and skill of these workers because it’s going to hurt the industry owners in their pocketbooks. All those certified alcohol counselors make their livelihoods on these jobs, so this change in the field must be a gradual process that respects these realities while still fighting for the gold standard in treatment providers’ skills. As with our clients, we need to bring many things to the treatment table including respect, with grassroots spirit and good clinical training skills, to assist clients in seeking their best life possible – their own “gold standard” if you will. Then we will really be practicing harm reduction psychotherapy.
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