Rethinking Addiction & Substance Use

Recently, I was in conversation with another therapist. Knowing I work a lot with clients struggling with substance use, he made the comment, "It must be difficult working with addicts since they’re so unreliable and don’t get better."

I asked him to clarify, and he shared that people with addiction are difficult clients because they often have relationship problems, use substances to avoid feelings, and frequently lie. When I asked what he meant by “addicts,” it became clear he made no distinction between people who use or misuse substances and those who are physically and/or psychologically dependent.

I was a bit frustrated. I tried to explain that he was referring to a wide array of clients whom I don’t find particularly unreliable. Yes, there are times when clients are using heavily and choose not to disclose their use at that time to me, but the withholding has valid reasons behind it. People are often ambivalent about giving up complicated behaviors that may be hurting them at the moment, whether it's substance use, abusive relationships, or binge eating to name a few. They may also be testing the therapeutic relationship at this time. In my experience, these dynamics can occur with any client and can be a meaningful part of the work.

This conversation also reminded me that we need to be cautious about dividing people into categories like “drug abusers” and “non-drug abusers.” Most of us have had some experience with drugs or alcohol that, in a particular time, was excessive or destructive. This includes clients whose substance use is not one of the reasons they are seeking therapy. Everyone has a relationship with substances and it exists on a continuum.

Despite this conversation, I respect this colleague in other areas of psychotherapy. The exchange led me to reflect on ideas and approaches that have guided me in my work with substance use over the years.

Addiction is Not a Fixed Concept

Arriving at a universal definition of addiction is something the DSM, therapists, and researchers have long struggled with. When an entity or individual finds a particular model or framework that defines addiction for them, it often comes with the belief that this represents the truth (Shaffer, 1994).

Clients who use substances in varying degrees are often grouped together under the label “addicts.” This all-or-nothing thinking reduces individuals to one category, stripping away their histories, complexities, strengths and resiliences. It also fails to account for the diversity and range of substance-related issues clients experience.

Substance-Using Clients Are Not Uniquely Difficult

In my work in inpatient, outpatient, and private practice settings, I haven’t found substance-using clients to be more dishonest or less committed than others. Clinicians often struggle with what they call “resistance.”  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.  This can lead clients to hiding their continued use and feeling shame about it.

The Limits of the 12-Step Model

12-step programs like AA can be enormously helpful. They offer structure, community, and spirituality that support people throughout the world in recovery. One of the 12 steps’ ideas is that “all addicts are the same” and you are not uniquely different from another addict. This can help some people resist cravings and self-destructive behavior. It addresses the temptation of comparing to others in the program and determining your use is not as bad as theirs. This has led some to think, “maybe I don’t need to attend meetings and can handle my drinking on my own” when they actually need the program to maintain sobriety.

However, this framing of “all addicts are the same” doesn’t work for everyone. I’ve worked with many clients for whom differentiating themselves from “all addicts” was essential to healing. For some, the path is complete abstinence. For others, it’s moderation. Often, it’s a process that evolves over time.

Understanding the Whole Person and What works for Them

Harm reduction psychotherapist Andrew Tatarsky (2002) emphasizes that substance use problems stem from complex, individual, psychological, social, and biological factors. He stresses the importance of understanding this with each client for treatment to be successful.

Psychotherapists, like anyone else, are vulnerable to absolutist thinking. We want to help and can get overly enthusiastic when a particular approach works well with one client or a group of clients.  When this happens, we can miss listening to the client we are working with and discovering what will truly help them.

A Brief Look Back: Freud’s Use of Substances

Psychotherapists' discomfort with substance use may, ironically, be partially rooted in its origins. Sigmund Freud—the father of psychotherapy—had a well-documented relationship with drugs. Johnson (2003) writes that Freud was “ostentatiously and lasciviously addicted,” idealizing both cocaine and nicotine, which he didn’t give up, even as nicotine contributed to his death.

Freud praised cocaine in letters to his fiancée, Martha Bernays. In 1884, he wrote:
"In my last severe depression, I took coca again, and a small dose lifted me to the heights in a wonderful fashion..." (Byck, 1974, p. 10–11)

In 1886, he added:
"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).

Given Freud’s example, it's not surprising that the field has struggled with how to view and treat drug and alcohol use.

There Is No One Answer—and That’s a Good Thing

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 can be helpful and help with organization, but need to evolve alongside different therapies that meet clients' actual goals and needs. This diversity also fosters continued creativity and learning.

Andy Sussman
Psychotherapy in Rockridge and San Francisco
sussmantherapy.com
510-909-2997
asussman11@gmail.com