Working with Addictions

By Michael Korson, MFT

Overview
These days I work a lot with clients coming to psychotherapy with issues related to addiction. These people are often struggling with dependence on alcohol, marijuana, pornography, sex, food and other behaviors that become habitual and often injurious to themselves. They often feel stuck with these behaviors and may have made many attempts to stop that failed in the past. Sometimes, these behaviors do not register as problems in their lives. Sometimes the problems these behaviors cause are glaringly apparent (a DUI, getting fired from work).

It seems to me that in my 15 plus years of doing psychotherapy in San Francisco and Berkeley, there are a greater number of clients now presenting with these conditions than ever before. Perhaps there are various reasons for this. Modern life has gotten particularly complicated and high pressured. The economy for several years now has been a source of a great deal of stress for people struggling to just stay afloat. And the access to the things that people may abuse has, especially through the prominence of the internet, gone (to use an internet term) viral.

I do not believe in one-size-fits-all explanations for what drives a person toward addiction. With each of my clients, we must do the hard work of inquiring into the meaning of these behaviors. And then there is more hard work of together figuring out how to replace these habits with ones that will be truly more helpful. The work is difficult; and all too often the addiction easy. A central component to addiction is the ease with which it is available. Often that means just reaching for another glass, taking another hit, surfing the internet…

There can be some confusion as to what constitutes addiction versus compulsive behavior or for that matter just problematic behavior. A client may wonder: Is it an addiction? A compulsion? Often these distinctions fall away as the client and I search for the meaning of the behaviors. More relevant in our work than finding the right diagnosis is the attempt to acquire a realistic perspective of the significance of these behaviors in a person’s life and the impact they have on that life. In general, we can say that in terms of addiction, a person will habitually indulge in this behavior in ways that take up a lot of his time, have some negative effect on other areas of his life (for example on relationships or in the job setting), and are difficult to cease (often a person has made several attempts to do so). These then tend to be some signs of an addiction.

And while each client and I must learn the meaning of his particular behavior, from my years of experience, I have come to identify certain key aspects of addictive behavior. These key components tend to be present regardless of the substance being abused. The addictive behavior can often be seen as a strategy for coping with something distressing in a person’s life. Through the use of these habits, a person hopes to ease the pain he feels in his life and instill a sense of control and predictability.

As Coping Strategy

Through the use of these habitual behaviors, a person endeavors to cope with something troubling in his or her life. At the heart of the behavior, then, is the intent to cope. But cope with what? Through psychotherapy we make this inquiry, and often what we discover is that the addictive behavior is an attempt to cope with what is (or is thought to be) dreaded, uncomfortable, distressing in a person’s life. That “something” is usually some powerful, underlying feeling of futility, unhappiness, or misery.

The intent in the use of say alcohol, drugs or pornography is essentially to get high. This person endeavors to replace feelings of unmitigated joy or uninhibited freedom for the underlying ones of dread and unhappiness. Of course, this is often not a conscious attempt. Unconsciously (and reinforced through habit) the person getting high wants to escape his current condition. It is a means, as one client put it, of “skipping over” something. In this regard, it’s an attempt to cope by not feeling what is believed to be unbearable to feel.

And to some degree that attempt is successful. When indulging in the behavior, no matter the substance, the person tends to feel a different set of feelings. Usually a person does feel high, giddy, without a care in the world. That feeling is, of course temporary, inevitably followed by the “hangover” (remorse for using this drug; hopelessness when recognizing dependence on it; accompanying depression). The high lasts until the experience wears off and the person comes back to his life; and what exists beneath the surface, these seemingly unmanageable and intolerable feelings which necessitate the need to escape, persists. Nothing has changed substantially. There has been some respite, albeit brief, from the misery. Only now that misery is compounded by the drug use and consequent adverse effects on family, relationship, jobs.

Often clients I have worked with who have been struggling with addiction feel very “stuck” in their lives. They have very strong feelings of inadequacy and incompetence, and they feel that their life is not progressing. These negative feeling are, of course, not easy to feel. In this regard, the use of pornography (for example) can be seen as an attempt to inhabit a space outside of reality (given how miserable reality seems). Pornography is inherently not real; the images one relates to are just that images and not real human beings (who have complex feelings and needs themselves). Use of pornography is fueled by fantasy (a realm that is by definition outside of reality). The escape to a place outside of reality is an attempt to exist outside of the feelings that reality evokes.

For others also struggling with a sense of a life squandered and unaccomplished, the use of alcohol and drugs is intended to numb oneself and one’s feeling receptors. To numb out is to not feel so bad, not feel so much pain. The quandary in this approach, of course, is that to be numb is not to feel at all: the good and positive feelings along with the bad are then unavailable. One is left with a numb sense and the repeated requirement of more and more substance (what is referred to as “tolerance”) so as to feel anything at all or to function even minimally.

Predictability

When working with addictions, it is vitally important to understand the role that predictability and the desire for predictability has in a person’s life. The repetition of these behaviors creates habit; and with any habit, a person comes to know just what he is going to experience. If it is the habit of drinking to the point of intoxication, if it is indulging in pornography or smoking pot, a person tends to know what will happen. He knows that he will get high; that he will feel differently in his body and his mind than he currently feels. He knows what exhilaration he will feel; what lack of inhibition he’ll experience. (He also “knows,” though this knowledge may be sequestered in hidden recesses of his mind, that there will be a low, a let down, and a reoccurring need to get high again.)

This method of instating a sense of predictability provides a way to feel in control of one’s life, especially when dealing with a vast portion of life experience which feels outside of that control. The feeling of being out of control, and thus terribly vulnerable, is a core component of anxiety. Much of what causes suffering is unpredictable: a sudden change in a person’s finances; an abrupt end to a relationship; a loss. Of course, there are predictable occurrences in life and these too can cause pain and suffering. With any significant change in a person’s life, there may be feelings of powerlessness, lack of control – often challenging a person’s stability and well-being. And when dealing with what is not changing in a person’s life – disturbing feelings of stagnation and ennui — there is often an accompanying feeling of powerlessness. A person who uses some substance is trying to reinstate a sense of control. He or she is trying to cope. The result, however, often falls quite short of the intention. A life of alcoholism becomes a chaotic life. The effects of chronic marijuana use or pornography often contribute to a life without direction, one of futility and stagnation. As one client put it when describing his drinking, his thoughts were mostly focused throughout the day on getting the next drink, and thus his job and his family life suffered.

I have found when working with my clients on their addictions and compulsive behaviors that it is fundamental that we understand how their behavior instills some sense of predictability in their lives. It’s important for us to see this function of their behaviors and then search for better ways of coping.

Psychotherapy

From my clinical experience, I have often seen that these behaviors have persisted for a very long time in a person’s life. It is not surprising to see that during the person’s childhood (perhaps beginning in adolescence) there was some use of some substance as a means of coping. In these circumstances, it is important to understand that this means of coping, of attempting to feel better, stems from a time when a person’s resources and abilities were much more limited than they are now as an adult. This awareness becomes an important step in our work together. In some sense the client is misidentifying himself as still being that younger person with fewer resources available. It is vitally important for the client to make this differentiation in time: to see that now is different than then.

One key resource – and one we emphasize in our work together — is the therapeutic power of an interpersonal process, of relationship. It is not infrequent in this work that the client and I see that going back to childhood, the client may have had little help in coping with what distressed him. In many instances, we see that parents or guardians were absent, not involved, or negligent in helping these people manage, tolerate and work through their issues. Often these people felt quite alone and left alone to their own devices to figure out some way to manage. The ways that they have figured out (the “solutions” that are these addictive behaviors) often linger till present day. And most importantly, that feeling of being on one’s own lingers as well. The work of psychotherapy, through the relationship that is at the core of this work, challenges those basic assumptions and feelings. The client comes to feel that he is not alone. (Of course there are times when referrals to support groups, sometimes rehabilitation programs, are necessary and also help the client feel less alone and recognize more resources that are available to him.) Through the psychotherapy relationship, the client learns to unlearn what he gathered from the past – that he is alone, on his own to figure out how to cope with life’s distresses.

The client has developed these coping strategies as a means to deal with what is thought to be unmanageable, too dreadful and painful to feel. At the heart of our work together is challenging this belief. Often this core belief is expressed when the client says “I won’t function” or “I’ll fall apart” if he or she truly faced these feelings. When feeling essentially alone, life’s distresses can be perceived as unbearable, unthinkable. Through psychotherapy, the client comes to see that what is causing distress in his life doesn’t have to be skipped over; he doesn’t have to anesthetize himself because of the pain in his life. The client learns to better stay with himself and his feelings. He doesn’t have to escape. He and I can then think together about what is causing suffering in his life and what real changes need to be made to alleviate that suffering. And he can open the previously shut doors to feelings, allowing for the painful feelings and also accessing the joyous ones as well.

An important dimension in this process is our examining other ways of healthier coping. I often say to clients that everyone deserves a break, some respite from what is difficult in life. We often talk about some of these more positive respites (developing hobbies, doing meaningful volunteer work, cultivating a quiet relationship to oneself through meditation or spending more time in nature). And, of course, we often focus on creating and strengthening other supportive relationships.

When addressing issues of addiction and the underlying issues that addictions are symptoms of, the work can be very painful at times. Often there are some very distressing feelings that a person has mobilized against feeling. And not infrequently the path to healing and recovery is not linear. Often in this process there may be relapse and the accompanying feelings of guilt, disappointment, and setback. But I have come to see from many of the clients whom I’ve worked with over the years, those who have made significant changes in their lives, that the “high” of working though addictive behaviors and better supporting oneself is incomparable to the high offered from the addictive behavior. The positive effect on one’s self-esteem and the sense of accomplishment that comes from doing this work is immeasurable and long-lasting.

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