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#TBT on PsychedinSF – In Defense of Addicts

As a therapist in training, I often felt unsettled (at the very least) and furious (at the very most) when trying to address my clients’ substance use. I had only heard of 12 step, abstinence-based programs and none of my supervisors could advise me otherwise. I often heard the same line: alcoholics can’t engage in treatment so your client needs to be in AA if you’re going to do any useful work. That didn’t feel right! My clients a) weren’t ready/willing to become abstinent or attend meetings, b) they didn’t all have the same problem with substance use and c) I refused to believe turning them away from therapy or making ultimatums would be helpful. It was such a huge relief when I stumbled upon Harm Reduction, an approach that truly honors where a person is at and helps them find answers within themselves. It removes the notion of “powerlessness” that can so often feel shaming or at the very least unappealing. In his article, “In Defense of Addicts”, Andrew Sussman takes a stand for addicts and users and reminds us that one size does not fit all. For a refreshing perspective on addiction treatment and possibly your own substance use, please read and share. – Lily Sloane, MFTi and Psyched in San Francisco Writer
Clients that use substances to varying degrees are often clumped together and labeled as addicts.  There is a widespread simplistic, all or nothing view towards drug and alcohol users that tends to objectify them. In my opinion this can miss the diversity, strengths and actual degree of substance problems with each person. -Andrew Sussman

…And really substance users, abusers as well.  Just last night I was in consultation with another therapist. Knowing that I specialize in working with clients struggling with drugs and alcohol he made the comment, “It must be difficult working with addicts as they’re so unreliable.” I asked if he could clarify and he further described his opinion that addicts are hard clients as they have problems with relationships, use substances to avoid feelings and situations, lie and he expected that most of my clients expressed such behavior regularly. When I asked what he meant by “addicts” it was clear that there was no differentiation with those that use or abuse drugs and alcohol and clients that may be physically and or psychologically dependent.

I found myself feeling frustrated and tried to explain that what he was attributing to substance users was actually true of a wide array of people and psychotherapy clients. I have not found people struggling with substance use or “addicts” to be particularly unreliable.  Sure, I have instances where my clients were using heavily or for some other reason, testing our treatment relationship. In my experience this can happen with any client.  When any client tests the therapeutic relationship by missing sessions or being “unreliable” it can be and often is a useful part of our work.

That being said, this colleague is also someone who refers most of his substance using clients to me and doesn’t have the experience nor interest in working with people who struggle with substance abuse or addiction.  In many respects I consider him a solid, experienced and insightful clinician. The conversation went on for some time and as a result I wanted to share some reflections.

  1. Therapists tend to specialize these days and even highly trained reputable therapists may have little to no training in substance abuse, use and addiction.
  2. We struggle to define addiction, abuse, use and treatment.  Arriving at an agreed upon definition of addiction has not been easy for any of us. It is something that the Diagnostic and Statistical Manual of Mental Disorders (D.S.M.), psychotherapists and science in general has struggled with. When one entity or individual has a definition or model, it is tempting to assume they have also arrived at the truth and the correct model (Shaffer, 1994).
  3. Clients that use substances to varying degrees are often clumped together and labeled as addicts.  There is a widespread simplistic, all or nothing view towards drug and alcohol users that tends to objectify them. In my opinion this can miss the diversity, strengths and actual degree of substance problems with each person.
  4. From my extensive experience working with drug and alcohol users in private practice and several treatment programs I have not found this population to be more unreliable or uncommitted to treatment than other clients.  Clinicians sometimes experience what they might call “resistance” with this population. I think the difficulty may be the expectation that such clients commit to the clinicians and treatment programs’ goals (generally immediate abstinence) rather than co-creating mutually agreeable goals that can be revisited together in treatment.
  5. 12 step programs continue to be enormously helpful for many drug and alcohol users. They provide much needed support, structure, and spirituality for people worldwide. The A.A. teaching that all addicts are the same may help some stay sober when in the throes of craving and rationalizations, but like any teaching, it never applies to everyone. 

Over the years I have worked with many clients who, when they stopped lumping themselves in with “all addicts” reached a pivotal moment in their treatment and from there developed a personal relationship with their substance use that worked for them.  Clients, then, determine their relationship to substances – sometimes it is complete abstinence, sometimes moderated use and often it evolves over time. I have found that coming to know the meaning and utility of the substance use is often an important aspect of the therapy.

Andrew Tartasky, (2002) a harm reduction psychotherapist in New York points out that substance use problems come from a variety of sources, psychological, social and biological and that these are unique to each individual. He stresses the importance of understanding this with each client for treatment to be successful.

Questions regarding meaning and utility of using substances and addiction in the field of psychotherapy can go back to Freud.  Johnson reports that the father of psychotherapy was “ostentatiously and lasciviously addicted” (Johnson, 2003, p. 3), idealized cocaine and nicotine, and refused to give them up eventually leading to his death from nicotine.

Freud’s fascination with cocaine was expressed in his letters to his fiancée Martha Bernays in 1884, “In my last severe depression I took coca again and a small dose lifted me to the heights in a wonderful fashion. I am just now busy collecting the literature for a song of praise to this magical substance.” (Byck, 1974, p. 10-11). He refers to cocaine and a host of other substances regarding its help with his social anxiety in his letters to Martha in 1886 as he wrote, “I was quite calm with the help of a small dose of cocaine…and accepted a cup of coffee from Mme. Charcot; later on I drank beer, smoked like a chimney, and felt very much at ease without the slightest mishap occurring.” (Byck, 1974, p. 164-165).  It’s easy to understand the field’s discomfort with how best to take on drug and alcohol use considering Freud’s relationship to them.

Perhaps my reflections here lead to more questions than answers. There’s no one panacea for substance use problems or human suffering and I think that’s a good thing. It leaves the door open for finding our own path and types of therapy that are a good match for our clients and us. Definitions of substance use, abuse and addiction need to evolve alongside therapies that meet clients’ actual goals. This diversity also fosters continued creativity and learning.

Andrew Sussman

Andrew Sussman

Andrew Sussman is a psychotherapist in private practice in Noe Valley. He sees individuals, teenagers and couples. Substance use and addiction is one of his areas of specialty.

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