Some Thoughts on Substance Use and Abuse

Gary Simoneau, LICSW and Howard J. Shaffer, Ph.D.

While we cannot refute denial is a potent force in our lives. However, it is worthy and interesting to consider the circumstance where denial has no role whatsoever. This paper isn't meant to wade into the controversy about whether or not drug and alcohol dependence is a disease or a matter of will. In the end, allegiance to one perspective or the other blocks the usefulness the shunned perspective has to offer (Gustafson, 1995). If denial doesn't exist, then choice becomes ascendant in thinking about drug and alcohol use or any other habit that can interfere with people realizing their potential. Spending hours reading newspapers can keep someone trapped just as surely as alcohol.

Shaffer (1992) suggests ambivalent conflicts emerge when positive consequences, often experienced early in a relationship with the object of addiction, are challenged by adverse consequences emerging later in the relationship. When this conflict stimulates painful ambivalence, denial develops to as a defense mechanism to split the conflict leaving the substance user able to focus only on the positive or negative aspects of their addictive behavior pattern. Therefore, clients in the psychotherapy office or in a confrontation with their spouses will swear up and down alcohol is killing them, yet turn around and be drinking again moments later. When stimulated by painful ambivalence, denial encourages clients to flee into health with little capacity to sustain their sober intentions or, alternatively, encourages them to retreat into a more exclusive bond with the object of their desires. Here we can see how denial functions in the development of an addiction. However, in treatment situations with people using substances, focusing on denial can make a bad situation even worse. A treatment focus emphasizing only denial misses how a behavior works for a client because the goal is to confront denial and to get the person to stop drinking or drugging. What the client gets out of their substance use is overlooked.

The problem, as noted above, is the wall that arises between the positive and negative aspects of substance use. Denial based treatments examine only the negative side of this wall instead of making the wall porous so the negative and positive aspects can be on "speaking terms." When the positive and negative aspects interact, extreme behaviors on both sides, either unachievable flights into health or increased substance use, are modified. Shifting the treatment focus from smashing denial to "exercising" the core ambivalent conflict allows for each side of the conflict to communicate with the other. Though clients who keep using substances often can appear intractable or unmotivated, they are not any different from the rest of us who resist changes of all sorts.

Resistance is at the core of what makes it difficult for people, even the most healthy, to achieve consistently good mental health. Albert Ellis noted, "I am still haunted by the reality, however, that humans - and I mean practically all humans - have a strong biological tendency to needlessly and severely disturb themselves and that, to make matters much worse, they also are powerfully predisposed to unconsciously and habitually prolong their mental dysfunctioning and to fight like hell against giving it up. No, I do not think they are masochistic - I think they are almost always extremely hedonistic, but they continually indulge in short-range rather than long-range hedonism, that they are obsessed with the pleasures of the moment rather than of the future (Ellis, 1987, p.365).

In other words, as obviously bad as a person's situation might appear to someone else, it's better for him or her to keep things the same. Instead of seeing short-term discomfort as a necessary investment toward long-term gains, clients, as Ellis recounts, prefer their short-term hedonism. When a therapist can consider apparently self-destructive behavior as a legitimate choice, clients have the opportunity to conduct therapeutic work in the safe surrounds of a behavior that is well known. Since this strategy does not ask clients to give up anything, they have less need to resist therapeutic interventions and they can explore all of the costs and benefits associated with a pattern of addictive activity.

Let's consider a case example. Ms. Jones comes to her first psychotherapy session saying her husband has told her she must stop drinking or he will leave her and take the kids. She's decided her husband is right and it is indeed time to stop. If the therapist immediately begins working with Ms. Jones, the therapist and Ms. Jones are in danger of not finding out how drinking works for her. Instead, the therapist asks her exhaustive questions about every imaginable aspect of her drinking from the brand she drinks, when, where, and how she drinks, all the way to whether she drinks with ice or without. After a time, Ms. Jones is getting annoyed with these questions. Other clients, however, enjoy this kind of work. They have never thought about how and why they drink what they drink. Neither has she. "What do these questions have to do with anything?" she asks. The therapist reassures her that everyone's way of drinking is different and we would like to understand how it works for her.

So they begin again with the therapist asking what her husband is like. Is he worth stopping drinking for? Ms Jones replies, "yes he has always stood by me. He works hard though, so I don't get to see him much" (a glimpse into alcohol as recompense?). The clinician persists asking further questions about the marriage and she says it's like the therapist doesn't believe her. Again, the therapist reassures her, but also notes many clients have chosen drinking over their spouses. Ms. Jones is wide-eyed, amazed to hear this, yet she knows full well marriages do end over a spouse's drinking. She thinks about it and, in turn, these thoughts act as the first inchoate wedges between her impulses and actions.

A therapist focused on denial might see Ms. Jones as further along than she actually is due to her apparent initial willingness to work on her problem. Denial didn't seem like an issue, but in fact it was as Ms. Jones was denying she even had a choice in the matter. Unfortunately, therapists and family members are fearful of substance users choices and react by steering the person toward the seemingly healthy alternative. Clients need the benefit of personal choice to stimulate the momentary pause and consequent moderation that consideration of options beget.

By avoiding the exploration of critical aspects of the conflict engendered by the choice between an unhealthy, but familiar option and a healthy, but uncertain option, therapists leave clients immature to meet life's shifting demands. As a result, clinicians often unwittingly send clients back into a world unprepared to meet its challenges. Spaulding Gray, the comedian/monologist, spoke about his learning to ski in It's a Slippery Slope (Gray, 1997). He can only make right turns with hilarious results. In life it's not so funny. The one directional life leaves behind broken relationships, lost careers, and ruined health. Clients may end up choosing a one way existence, but if we clinicians have done our work, they will have learned to take up the other side of a conflict before deciding what is best for them.

References and Suggested Readings

Ellis, A (1987). The impossibility of achieving consistently good mental health.

American Psychologist, 42, 364-375.
Gustafson, J. P. (1995). The dilemmas of brief psychotherapy. New York: Plenum Press.

Gray, S. (1997). It's a slippery slope. New York: The Noonday Press.
Miller, W.R., Rollnick, S. (Eds.). (1991). Motivational interviewing: preparing people to change addictive behavior. New York: Guilford Press.

Prochaska, J.O., DiClemente, C.C. & Norcross, J.C. (1992). In search of how people change: applications to addictive behaviors. American Psychologist, 47, 1102-1114.

Shaffer, H. J. (1992). The psychology of stage change: the transition from addiction to recovery. In J. H. Lowinson, P. Ruiz, R. B. Millman, & J. G. Langrod (Eds.), Substance abuse: a comprehensive textbook (Second ed., pp. 100-105). Baltimore: Williams & Wilkins.

Shaffer, H. J. (1997). The psychology of stage change. In J. H. Lowinson, P. Ruiz, R. B. Millman, & J. G. Langrod (Eds.), Substance abuse: a comprehensive textbook (Third ed., pp. 100-106). Baltimore: Williams & Wilkins.

Shaffer, H. J. (1994). Denial, ambivalence and countertransference hate. In J. D. Levin & R. Weiss (Eds), Alcoholism: Dynamics and Treatment (pp. 421-437). Northdale, N. J.: Jason Aronson.

Vaillant, G. E. (1983). The natural history of alcoholism: causes, patterns, and paths to recovery. Cambridge: Harvard University Press.

Gary Simoneau, LICSW, is a psychotherapist for Lahey Clinic Community Group Practice in Concord, MA, and is in private practice in Somerville, MA.
Howard J. Shaffer, Ph.D., C.A.S., Chairman, Advisory Board, Behavioral Health Online; Associate Professor & Director, Division on Addictions, Harvard Medical School

 

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