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Both-Sides-Now Therapy

Recovery is rife with conflicts between wanting to use drugs and wanting to stop or cut back. In "integrative addiction therapy," addicts can learn how to give voice to, and get over, this inner struggle.

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By Scott Kellogg

10/18/12

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As a psychologist working in addiction treatment, I spent a number of years searching for effective ways of helping those who were wrestling with alcohol and drug problems. "Integrative addiction psychotherapy" is my evolving attempt to synthesize the paradigms, strategies, and interventions that I found to work best. These include harm reduction psychotherapy, schema mode therapy, relapse prevention, gestalt chairwork, and contingency management. It is my intention to create a model of therapy that is scientific, humanistic, and of potential use to all patients, including those taking addiction-focused medications.

I also hope that it can answer these two questions: What are the forces driving my patients’ problematic use of substances? And: What can I do to help them heal and recover?

Dr. Andrew Tatarsky, one of the leaders of the “harm-reduction psychotherapy” movement, argues that the forces that drive people to use drugs and alcohol need to be respected and, in many cases, treated before the person is willing to alter, reduce, or cease his or her use of substances. Of course people use substances for a wide range of (often overlapping) reasons: to experience pleasure, to reduce psychological pain, to cope with neurobiologically based cravings and mood dysregulation, to alleviate suffering due to medical problems, to affirm membership in certain networks and subcultures and, as harm-reductionists emphasize, to cope with racism, poverty, homophobia and other forms of social disenfranchisement.

In turn, patients also carry within them different kinds and degrees of motivation to change and to heal. These forces include threats to dreams and ambitions, existential and spiritual desires, relational difficulties, legal problems, health concerns, and difficulties maintaining their addiction lifestyle and addict identity. In addition, problematic substance use is not only a symptom; over time, it frequently becomes a problem in its own right as people enter into cycles of substance-driven desire, craving and dysphoria that function in a manner independent of the original motivating forces.

This complexity can be found in many patients. For example, a patient I will call “Chad” often engaged in low-level social drinking with colleagues and occasional higher-intensity, alcohol-fueled partying with a specific subset of friends. At other times, however, he also engaged in methamphetamine-driven searches for sexual intimacy that were particularly destructive because they led to major disruptions at work and high levels of tension in his family. “Parker,” in turn, demonstrated six different patterns of alcohol use: (1) social drinking; (2) “life of the party” drinking; (3) sexual drinking; (4) solitary, self-soothing drinking; (5) depressed drinking; and (6) family-based drinking. Different combinations were central at different times in his life. And “Peter,” who had previously overcome a career-damaging problem with alcohol, was upset that he kept using cocaine whenever he spent time with a certain group of friends. Unwilling to end these long-term relationships, he sporadically but repeatedly engaged in drug use episodes that threatened to destroy his marriage—if discovered.

These complicated patterns of drug taking call for a personalized approach to treatment. To this end, I believe that a “multiplicity of self” model—the view of the personality as containing multiple parts, voices, modes, archetype, or internal objects—can be quite useful. Not only can this view of the self be found in contemporary psychotherapies, but it also has been a hallmark of addiction culture—usually in the metaphor of Dr. Jekyll and Mr. Hyde. (While this particular literary reference may be overly simplistic, it speaks to the experience of the self as a struggle among different aspects of the self.

An excellent place to start to identify these internal forces is by means of the “decisional balance,” in which the patient articulates the positive and negative aspects of his or her substance use and the perceived positive and negative aspects of changing it. Modes can also be identified through a detailed assessment of the patient’s recent substance use. The constellations of emotions, desires and energy that emerge from this process are the "modes." They can also be identified through a detailed assessment of the patient’s recent substance use. The goal is to develop a comprehensive picture, or “mode map,” that will allow the therapist and the patient to understand how he or she is using specific drugs in specific contexts to achieve specific results.

In moving beyond diagnosis into treatment, a core aim of the work is helping patients develop the part of the self variously described as the ego, the “inner leader” or the “healthy adult mode.” It is with this inner leader that the therapist will strive to create a plan of action that respects the needs of the various parts while also serving the health of the whole person.

As the process unfolds, I like to focus the patient on four dimensions: (1) balancing the motivational forces, (2) healing the underlying pain that drives the drug use, (3) monitoring and reducing the substance use, and (4) creating visions of a future that are meaningful and reinforcing. To do this work, I believe that it is vital to have mastery over what Dr. Tatarsky and I see as the core “mechanisms of change”—the most important of which is the therapeutic alliance, as this is the foundation of all effective therapy. Building a good alliance with the patient requires of the therapist love, empathy, authenticity, optimism, courage and a determination to see it through.

Ambivalence, a hallmark of addiction, can be addressed as a conflict among different parts of the self—and "chair work" can be an effective technique for working on it.

Ambivalence, a hallmark of addictive disorders, can be addressed as a conflict among the modes or parts of the self. I have found the “chairwork” technique an effective way of engaging with and balancing these internal forces. In chairwork’s most basic form, the patient alternates between two chairs—with one representing the mode(s) that wants to use alcohol or drugs and the other embodying the mode(s) that wants to reduce or eliminate substance use. The goal is not necessarily to encourage an argument between the conflicting parts—a mutually witnessed, deeply felt expression of distress and desire can be catalytic in itself.

To work therapeutically with the patient’s underlying psychological pain—as well as with the dynamics of addiction—it is helpful to use what I call the “vertical and horizontal interventions.” Vertical interventions focus on the inner suffering and psychopathology, and include the relational (“creating safety” and “witnessing the narrative”), the cognitive (identifying and challenging his or her destructive thought patterns and beliefs), the behavioral (doing “exposure” work and reinforcing desired behavior), the experiential (giving voice to self modes and re-enacting difficult situations), the existential (clarifying values and taking actions based on them), and the meditative and self-soothing (entering states of deep relaxation; detaching from, and observing, thoughts and experience).

Horizontal interventions, in turn, are specifically oriented toward recovery—ending or reducing his or her substance use. These techniques include “substance use management,” or finding safer methods of drug taking; “relapse prevention,” or coping with high-risk situations; and “contingency management,” or developing positive-reinforcement systems. In terms of drug use during therapy, I take a “gradualist” perspective that the ultimate—but not necessarily immediate—goal of addiction treatment is abstinence, “true” moderation or nonaddictive use. However, given the complexity of addictive disorders, it may take the patient a while, perhaps a great while, to get there.

The following three vignettes may provide a feel for this psychotherapeutic work:

With Chad, I first set up a contingency management system in which he would pay a slightly lower fee for therapy if he did not use methamphetamine that week and a dramatically higher one if he did. In terms of modes, he was originally torn between a younger part that wanted to use the drugs and an older scolding part that criticized him harshly for doing so. This dynamic, while common, is inherently unstable and will not support long-term recovery. Over time, we were able to empower the inner leader to say, “This is my life. I do not want to use methamphetamine anymore. It is not serving my goals and it is not a reflection of who I really am.” We also worked on finding ways to achieve intimacy that were not based on drug use.

With Parker, we set up guidelines for moderation and monitored how well he followed them. Much of the time was spent working with his anger, fears, traumas, shame, and sorrow. Two of Parker’s modes were embroiled in a deep and longstanding conflict, and we tried to find creative solutions to this dilemma. By the end, his inner pain had been somewhat diminished with the result that he chose to embrace only his social and family-based drinking patterns—leading to a dramatic reduction in the frequency of problematic drinking.

With Peter, we did many dialogues between the healthy adult/inner leader and the younger drug taking mode, allowing him to speak deeply about the stress he was under and the challenges he faced. We explored some of the difficult aspects of his childhood as this was a contributor to the rebelliousness manifested in the drug taking. We discussed actions he could to take to create a future that would be attractive and prosperous. Since he was not ready to end his substance use, we worked to reduce the frequency of the episodes and to minimize the danger when he did use. We also debriefed these episodes and sought to build on the insights gained from each encounter.

On the one hand, my goal is to help my patients rework their traumas, challenge their critical inner voices, confront their fears, develop and use their “voice” in assertive ways, with the aim of taking the actions necessary to create lives of meaning, purpose, and health. On the other hand, I work to help them understand their triggers and cues, assess the levels of harm, take steps to change their use patterns, deal with difficult situations and create meaningful systems of positive reinforcement. It is my hope that “integrative addiction psychotherapy” and approaches like it may enable us to more fully and deeply help those who are locked in the prison of addiction. 

Scott Kellogg, PhD, is the former president of the Division on Addictions of the New York State Psychological Association, a Schema therapist, and a clinical assistant professor in the New York University Department of Psychology. His websites are Transformational Chairwork and Gradualism and Addiction Treatment. His email is scott.kellogg@nyu.edu.

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