We Don't Treat Brains, We Treat People
The Meaning Dimension
The acute effects that drugs have on the brain are rewarding and become meaningful in relation to the whole person in his or her social context. People use drugs because they feel good and are reinforcing in some way. People who use drugs in problematic and addictive ways do so for reasons that feel vital to the user’s well being or survival. The pleasure, satisfaction, escape or high is always in relation to suffering and pain. There are several broad categories of suffering that render people vulnerable to problematic substance use.
Dr. Edward Khantzian of Harvard coined the “self-medication hypothesis” in 1985 to describe the use of substances as an adaptive attempt to heal or self-treat suffering. “Fixing” may actually refer to an attempt to fix something that feels broken inside. Depression, anxiety, stress, grief, boredom, despair, rage are common companions of problematic substance use. The turn to the substance may also reflect inadequate capacities to self-regulate feelings, soothe or comfort oneself such that feelings are experienced as overwhelming, confusing and frightening. In these cases the substance may feel necessary to one’s psychic survival and to maintain a sense of control of feelings and behavior.
- Rebelling against the Inner Critic
The release afforded by the drug effect is frequently a release from a generalized sense of inhibition, an inability to express one’s feelings, needs and vulnerability spontaneously in life such that one feels dead, cut off, disconnected and tense. The inhibition may be a response to a demanding, perfectionistic, self-critical personality style related to a harsh “inner critic.” The critic may not allow one to relax because one’s work is never done, one’s achievements are never good enough, one may be filled with anxiety about the threat of failure or depression over feeling that one has already failed. The substance is hard to give up if it is the only key to one’s liberation from the tyranny of the inner critic.
- Interpersonal Meaning
The reliance on a substance as a form of self-care frequently also reflects serious difficulties in interpersonal relating: profound mistrust of others, shame at expressing needs to others, and so on. Here the substance may become the more reliable parent, friend and lover. Drug use may also free people to express feelings and needs in the act of using that people are unable to express in words interpersonally, such as anger at feeling controlled by a boss or spouse that one feels too vulnerable or insecure to express directly. One patient said, “While I don’t feel safe enough to tell my partner that I resent the way he speaks to me when I drink too much, I can continue to drink too much to defy his efforts to control me and express my anger by killing him off in my mind when I am drinking.” Another patient said, “my drug use is my cry for help, the way I express my need to be cared for, my way of saying I am in agonizing emotional pain and never learned how to ask for help in the abusive family I grew up in. Please don’t reject me as my parents did, help me learn how to care for myself in a healthier way.”
- Social Meaning
The pleasure afforded by the substance may be particularly important in relation to a life in which there are few other sources of pleasure and satisfaction available such as lives of poverty, homelessness or increasingly common work lives in which the hours demanded leave little time for self-care and recreation. Mary is a 38-year-old attorney and mother of three young children. She is deeply dissatisfied with her husband in many ways, including sexually. She has great difficulty feeling and expressing anger and tends to direct anger and criticism toward herself. She has been injecting Oxycontin for the last year, originally as a way treat severe back pain, but increasingly to manage the stress of being a perfectionistic care taker of others, to quell her dissatisfaction and growing despair about her marriage and because she experiences the hit she gets when she injects in the following way, “the syringe is like my lover delivering the most perfect feeling like a wonderful orgasm.”
- Trauma and Dissociation
Sometimes the reasons for using are very much in the user’s awareness. However, in people who have experienced significant trauma early in life, substance use may become meaningful in ways that are outside the user’s awareness. If you ask these users why they use, they may not be able to say more than “I felt like getting high.” Trauma is typically coped with by dissociating, cutting off feelings and ridding oneself of parts of the self that threaten to bring about more trauma by overwhelming one’s capacity to function. Anger, sadness, grief, shame, humiliation, aliveness, curiosity all may become threatening and need to be suppressed and denied. These vital parts of the self may live in vague discomfort, just out of awareness, leaving the trauma survivor feeling tense, dead, tuned out, like a ghost, or “like Frankenstein” as one of my patients described himself. The substance use can provide the user a temporary experience of being able to connect with these parts and feel alive. In these people, excessive substance use is a meaningful reaction to trauma as an attempt to cope with what may otherwise be unmanageable pain.