The Holistic Solution To Addiction and Emotional Upsets
Family therapist Doreen Maller shares her innovative approach to treating families challenged by addiction or trauma. A Fix interview.
Doreen Maller, MFT, PhD, began her practice in community mental health with a specialty in high-risk children and their families. She has a private practice in San Mateo, Calif., and is a professor of the holistic counseling psychology program at John F. Kennedy University. Maller has contributed to several books about feminism and youth violence, and is the editor of a book series on community mental health.
Throughout the years, Maller has helped families who have been affected by substance use and addiction. “Substance abuse just integrates into a family system. It is wise to figure out if it is present when starting with a family because as a family issue, it can explain so many things,” says Maller.
“Therapy is a place where people come to discuss and confront negative patterns in their lives, make plans and begin action toward positive change. Often a conversation with a family therapist is the first time issues of drug use and addiction are shared. From a family perspective, these issues touch all family members. There can be shame, grief, confusion, anger. By talking about substance use’s impact on the family, the conversation can raise consciousness and help determine the course of treatment, whether that’s behavioral therapy, or a higher level of intervention, and the very act of sharing and bringing someone into the story can be the first step toward positive change.”
The Fix Q&A with Maller follows.
What does a holistic approach involve?
In a holistic point of view, you’re looking at a whole person in a whole system in a whole society. It can be described as a whole person model of mind, body, and spirit. However, to me, “holistic” can go inward and outward. Holistic encompasses the person, their belief structures, the society they live in and their physical health, trauma history and family system influences. There is a movie from the 1960’s called “Powers of Ten” that starts with a couple sitting on a picnic blanket, and then it transports the viewer to the outer edges of the universe by showing the couple in the park that they’re in, and then the city that they’re in, and then the country, and finally the universal view of the earth. It also travels inward and shows the people’s cells and atomic structure.
This is my view of holistic family therapy. You have to be able to travel all the way into the cellular level, and all the way out to the universal level in order to comprehend the family in their true experience; what are the physical consequences of their use and have we addressed them? Are there criminal and legal aspects that have to be addressed? Are there referrals needed for group work, AA meetings, detox, rehabilitation? Might there be mental health issues or trauma to explore and address? Should there be a team approach, or will a single practitioner do? In this way, the whole of the person and family are considered on a multi-level basis and a treatment plan can be designed to best suit the needs of the family.
How does this relate to addiction?
The holistic view fits perfectly into what the addiction and recovery world looks like because if you’re only dealing with the mind, you forget the body, and you can miss the complexities of drug use and dependence. One individual could literally take medicine for back pain and become addicted because something happened in their chemistry, where another individual might not. A key to familial understanding of addiction is embracing the complexity of the issue.
Working toward resolution might require multiple approaches of connection, education, rehabilitation and understanding. When you work with families, there are often conflicting feelings, as well as deflection and denial. Part of the role of the therapist is to be an explainer - to help the family recognize where they are in their addiction journey and the impact of their history, their present, and the potential of their future together. Therapy can help encourage motivation toward positive change. It can be a safe place to explore and heal from trauma. It can be a place to be educated on the impact of addiction on families, and a place to learn about the resources needed to heal and recover.
What about the mind component?
A lot of modern therapy is about behavioral changes. The abstinence model promotes the idea to keep doing positive things and stop doing negative things. The more we know about neuroscience, the more we know that the brain can be retrained. It can get stuck in negative reward patterns, but not permanently. For example, we know that new neural pathways can be built after stroke or a brain injury. Addiction carves a neural pathway that has a lot of perceived negative behavior attached to it, as well as positive reward since the substance makes you feel good, even though it produces negative behavior.
Reprogramming the brain to build new neural pathways that also have positive awards, and urging the client to start traveling down that road and create permanence in a new and positive way of being is key to behavioral work. Doing more of what is healthy and positive and less of what is negative and destructive. These skills are often taught in programs that stress self-awareness, meditation, emotional regulation and self-responsibility.
Is the mind and brain the same thing in this sense?
In this modern time, the mind and brain are seen as kind of the same. In some ways they are. The narrative part of the brain is the stories we tell ourselves, and in some ways it’s the behavioral side too. In psychotherapy, we can work both sides. The behavioral model retrains the brain, and the psychotherapy model deals with the stories and rewrites the new narrative. Perhaps the mind can be seen as the place where the stories are told, so the mind holds stories of trauma as well as positive memory. In therapy, trauma and family dynamics are explored with the idea that working through trauma can relieve emotional stressors.
What’s the distinction between the mind and body when it comes to addiction?
Cognitive behavioral therapy uses brain-power to redirect body power, so if your body has a physical craving, the brain can be trained to say “I won’t succumb to that.” You’re using thinking power to override what could be a craving that manifests in the body. Restructuring the body or the brain is about learning and re-patterning new ways of being. The brain has ways of doing things because you’ve always done them that way. Think about when you drive on a road every day to get from point A to point B. After driving the same route over and over again, you don’t even look for the roads anymore. Getting to your destination becomes an automatic function. Think of this in how it relates to a negative behavior. The behavior is the road; it’s just what we know how to do.
In order to form a positive function, you have to carve a new route to the brain and do it often enough that it becomes second nature. In terms of a commute, there is often more than one way to get somewhere, so you can change your route, and after you drive that route a while, you barely have memory of the first route. But if you go down the first route again, you do remember it and it becomes comfortable again. That’s what a relapse looks like. You’re starting to take a new route and the all the sudden you veer off to your original route and think “I’m comfortable here so I’ll keep going this way.” The idea is stay on that new road and do what you need to do to make it your routine way, including finding the positive rewards and aspects of this new way of being. It takes a while. You have to commit to the new path, and commit to it over other paths that may be more convenient.
The mind is the part that chooses the road to begin with, and these choices can be informed by so many things: trauma, circumstance, emotional discomfort. However, the body can lead a person into addiction as well, if substance use began with a physical issue. Dealing with the pain of detoxification and the physical components of addiction are all components of the rehabilitation process. Typically programs are needed that address the complexity of each person’s and indeed each family’s road to recovery - physical, emotional and spiritual.
How does the spirit fit into all of this?
Hope and faith are strong components of rehabilitation and recovery. Spirit is a cornerstone of AA, and focuses on believing that there is something more important and bigger than you are. Because sometimes when a person is in the throes of addiction, they can get very self-centered and only think about where they can get their next fix. Their whole world gets very small. Letting in a spirit component starts to crack open that spirit world so the person begins to be aware of something other than himself, something bigger that can hold one in love and care as they go through the process of recovery.
But that’s not all of it. For families in recovery there needs to be faith that things can improve, that each individual can find their strength and resources, and in the darkest moments, there is the comfort through a sense of hope, faith and prayer that we will not be abandoned and are not alone.
What is your approach to treating addiction?
As a humanistic psychotherapist, we say that every story is different even though they have similarities, and you have to stick with every person because some people’s stories start with trauma, some start with casual use, still some start with everyone in the family having a substance abuse problem or a system built around acceptable substance use.
For instance, a mom comes to see me because she’s depressed, and while talking about her depression, I learn that she suspects her son is stealing jewelry from her. When I ask her why she thinks he would steal from her, she says, “he’s going through a hard time because a couple of his friends died from drug overdoses.” This prompts me to ask if she ever considered that her kid has a drug problem, and this conversation opens up a whole new door. If I only dealt with her feeling depressed and not being happy with life, rather than trying to understand a broader view of what’s going on in her whole story, I would not have learned about her feelings of powerlessness around her son having a drug problem.
As a family therapist, I often find that the person in active use may not be my client. I may be working with a sibling or a parent who presents these circumstances to me. At that point I see myself as an educator, and have a responsibility to help the family understand where they are and what they might need in terms of support and recovery. That might include more services, or a treatment program. I will partner with the family as a kind of case manager trying to determine the best solutions for this moment in their lives.
What happens after you identify a problem?
I approach these situations from a family system perspective, and I try to answer the question, “what is this family going to do next?” I agree with the notion that you can’t do anything that the person with the problem doesn’t agree to, but I also believe that most people lack the intrinsic knowledge of know how to navigate their health insurance, and what is available in different step levels and programs for detox and substance abuse. Sometimes I’m just informing patients about their options like AA, or outpatient and inpatient programs, and helping them find what’s right for them.
For example, people can land in programs that don’t seem to be helping. Helping a family understand that systemically there are protocols to follow because insurance often covers the lowest levels of intervention before they fund more intensive levels. The therapist can help reframe this experience to explain that when an approach doesn’t work, it isn’t exactly a failure, but rather a mismatch, and then give support to the client or family to navigate the insurance system toward a more appropriate level of care.
What specific approaches do you use with families in crisis?
As a family therapist, I am often the first contact a person or family has when they initially realize that they, or someone in the family, has a problem. So a lot of my work is helping with the realization of the issues and finding other community resources for people as they move toward recovery solutions. If I’m talking to someone in the family who isn’t perceived to have the problem but is looking for help, I use Elisabeth Kubler-Ross’s stages of grief model quite a bit. Denial, anger, bargaining, depression, and acceptance can provide a road map of what the journey might entail. When I explain to an individual or other family members that they’re not the first people who have dealt with an addicted family member, and that people have really thought hard about the processes around getting through this, sometimes the idea that they’re in a process makes the whole thing less isolating.
I also use the change wheel. Before I tell people “this is what you can do” and “this what interventions look like,” I explain the wheel. In many families, the person they are concerned about is not even considering change, even though others in the family are growing impatient. Using a visual tool like the change wheel explains that. There is a whole process of preparing to make changes in your life which is about the first half of the wheel, and then making the change is the rest of the wheel.
Once, I worked with parents whose child was serving a two-year sentence at a therapeutic boarding school. I was going through the cycle of change with the mom and she said, “I’m ready for change, my daughter’s not even thinking of change, my husband is saying ‘how come we all haven’t changed yet?’ and my other kid is just frustrated. So here we have this wheel of change, but everyone in the family is managing it differently.” I thought that was brilliant. When treating one person, it’s easier to tell where they are on the wheel of change, but in a family system, everyone is in different places. It adds to the complexity of the problem.
How do you get family members to connect when they’re in different stages of change?
As a relationship expert, the challenge is to teach people how to communicate with each other, because often when you’re dealing with families in crisis, people aren’t talking to each other, and there may be a lot of manipulation, anger and resentment going on. Getting people to talk about how the family is in crisis is the first step. We can start the conversation with one person or more.
Using a systems approach, if you change one person, you change the whole system. If you start with one person and that person begins to change, there is this hope and possibility that the whole the system can change because one person is changing. If you raise consciousness and awareness in one person, this opens up the possibility that things can be managed differently. If everyone can admit that the family has a problem then you can begin the process of addressing the problem. This may involve sending the family to AA meetings or codependency meetings, or helping to change their ways of socializing.
Have you ever had a child come to you about an addicted parent?
When I was an intern, I ran a drug and alcohol rehabilitation model for juveniles after their first arrest. Instead of going to juvenile hall, they came to me for 10 sessions. I did this for about two years and met with about 90 kids. I’d ask them questions like “who was the first person who turned you on to drugs?” It was eye-opening. What was most interesting though was that many kids who I talked with were telegraphing for the family system.
We call this the “identified patient,” meaning that sometimes a kid is pulled into therapy because of misbehaving or failing in school, and it turns out the kid is having a problem because the family is having a problem. In these cases, a child is the family’s gateway into the mental health world, and a gateway into a system of care for the whole family. Working with a family to understand the impact of the parent’s behavior on the child is a critical component of family work.
How do you uncover family issues in these situations?
If you’re only addressing the child’s behavior, you could miss the much bigger issues. In my early years as a therapist, I had many kids who were expressing violent behavior in their classrooms. I noticed that everyone was melting down around 11:00 AM, and I hypothesized that it was because they were hungry. I started digging into the family system and trying to understand why the kids might be hungry. I learned many different reasons. Some weren’t eating breakfast because their parents were in jail for substance use, and no one in the family was feeding them regularly. Others lived with a grandparent who was busy taking care of other grandkids, too. Some were living with a parent with a substance issue.
Managing a family that is affected by use and addiction is very difficult. In many cases, we had to involve a larger system such as family services. While working with a child on behavioral issues is necessary, deeper systemic change can only happen by including the whole family and working with the parents to understand the impact of their choices on their kids. Working through the feelings and emotions of this takes time.
It seems that you truly believe in the holistic approach. Can you explain why?
Issues of addiction, emotional distress, trauma and family issues are very complex. I believe that complex problems require complex interventions. The holistic approach challenges the care provider to consider many aspects of care, compassion and connection. It encourages the therapist and the family to work together as a team toward family stability and strength. Working this way allows me to continue exploring options with families and promote hope in their road to recovery.