The Importance of Strong Emotions in Addiction Psychotherapy

By Mark Green MD 09/29/16

The therapy has to build security through titrating the anxiety that always accompanies emotional breakthroughs, just as foam and roar precede a wave.

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The Importance of Strong Emotions in Addiction Psychotherapy
Feeling is better.

The image of the calm, “neutral” therapist maintaining his equanimity in the middle of a turbulent session with a patient, a stable ship in a stormy sea, is deeply ingrained in the public mindset. Some patients may try to mirror their therapist’s neutral presentation despite their struggles with powerful emotions, but this can impede the progress of therapy since the patient’s ability to connect with and discuss their deepest emotions can be an important asset to treatment. At the same time, addiction therapists may fear that some patients will relapse if they are unable to manage the strength of powerful negative emotions. Mark Green, MD, describes a case in which he encourages a young patient to dig deeper…Richard Juman, PsyD

Addictions treatment has tended to steer clear of strong emotions. However, I believe that we have to stir up feelings if our patients are to experience a true recovery, and be able to live vividly and with intimacy.

I’m an overeducated, English, male doctor who was brought up to view emotions as messy, wild things that interfere with rationality and will. My training reinforced this. CBT, psychopharmacology and traditional psychoanalytic approaches prized insight and neutrality, and often confused emotions with anxiety - to be managed. If feelings did get aroused in session, patients might cry or leave, but get too disorganized to think. Worse was when something devastatingly traumatic was spoken of, but so matter-of-factly, with such incongruent affect, that I’d sometimes miss that the content was especially evocative at all. But emotions trumped logic every time the patient left my calm office for their turbulent worlds, rendering our fine relapse prevention work useless. They’d use or drink and I knew it erupted from the affects that churned like hot magma under the crust. Others might get some sober time, whether white-knuckled or blissfully and naively confident, but then relationship turmoil, an argument at work, or a stumble upon trauma that engendered dissociation would dash them against the rocks of relapse.

Techniques to inoculate patients against overwhelming affect are much more common now. Dialectical Behavior Therapy targets both behavioral responses to, and the capacity to tolerate, emotions using acceptance and mindfulness approaches, which pop up in many modalities. Another approach is to work experientially, actively evoking the feelings in the session, making them discernible, meaningful and transformative. There are many varieties. Scott Kellogg has described one approach—Transformational Chairwork—on Professional Voices. The experience of feeling and expressing feelings mindfully, whilst being deeply understood by another, is so compelling that people "get it" quickly, without teaching: it’s natural. As patients taste the emotional freedom and connection that might come if they can only stop hiding with drugs or alcohol, their motivation to use less increases since it becomes clear to them that their use is obviously getting in the way. The traditional tenets of addiction treatment begin to make sense when they are offered and are more easily adopted. There’s a new orientation to the treatment: toward authenticity, being seen and living fully. Along the way, they are building confidence that they can tolerate distress, which itself correlates with reduced craving and avoidance behaviors, including drug use.

Here’s an example. “Tom” was a man in his early 20s who came in addicted to opiates. At college he’d sustained an injury that ended his athletic aspirations. He’d been prescribed opiates, but with the sudden change in life plan and the removal of the constraints that college sports’ drug testing had provided, he escalated his dose, becoming addicted. After a brief buprenorphine course, he transitioned onto a monthly naltrexone injection. He was depressed and anxious and started on antidepressants and therapy. He had the usual slips but generally was eager for relief, and did pretty well. He changed his peer group, meditated and exercised, but also continued to drift between jobs, shy away from relationships and need antidepressants. It felt as if he was always trying to be a good boy, but his heart wasn't in it. One session, he seemed especially flat and lost. A text buzzed on his phone and, after glancing at it, he tossed it on the couch. I asked what it was. "Oh nothing. My Dad checking in. He does that every night."

"What are you feeling, because you seem less than delighted?" 

"Nothing. It’s nice, I guess."

"Sure, you appreciate his gesture. Underneath that, though, what else are you feeling?"

"It’s hollow. He does it automatically, everyday. But he doesn’t really want to hear anything."

"Hmm. what feelings are coming up for you now, as you think of him not wanting to really hear about you?"

"He’s a busy guy. His new wife’s sick, you know."

"Okay...and when you think of him not wanting to hear about you, really, that he texts you but somehow is checked out, what feelings come up for you?"

Tom shifts in the chair, crossing his legs and flicking his fingers. He’s more engaged and activated, but still steers clear of his own feeling. "I shouldn’t complain. He’s put up with me through all this."

"You’re feeling for him. You care about him, you’re grateful. But there’s something else, isn’t there? Another feeling in you when you think about him half-heartedly checking in. Maybe not so comfortable for you. Would you be willing to look at that other feeling with me?"

He paused a moment. "Well, I suppose I’m a bit tense. In my shoulders…and my legs feel ready, you know? To move or run."

"What feeling do you think this is, that’s building in you? When you think of him not really noticing what’s going on with you?"

"I’m pissed." Tom looked troubled, and tense. "He doesn't really give a shit. You know he was rough with me. He coached me and was rough, drove me hard. I liked football and all, but he didn’t give me any choice. I had to be the best." His hands were clenched and his breathing more shallow, quick. 

"Tom, is there a specific moment coming to mind, with this feeling?"

After a pause, Tom recalls, "There was one night, after a game. I was off, for sure. Probably cost us the game. He was mad! He kept me at the field afterwards, throwing and running, throwing and running. I was so tired! I’d practiced, played a game, it was dark. He was shouting at me. My friends were just watching. It was humiliating. He was shit-crazy." He’s still tense, and his fist taps the chair as he lets out a deep sigh.

"Let’s allow that anger up for once. You feel it? Underneath that tightness, balled up?"

"Oh yeah. It’s hot. Right here." He puts hand to his chest. 

"Good. Stay with that. Let that fill you. What does the anger want to do to him, if it could just burst up, could run amok? If it fills you?"

"I’d scream at him. You know, really loud. Tell him he’s being crazy. That I’m done."

"What do your hands want to do?"

"Oh. Punch, I guess."

"Where?"

"In his chest, like this."

"What does he do?"

"He’s surprised. He’s still angry at me though, disappointed in me."

"And you? You get that your play wasn’t so great, but that’s not the point. What feelings are in you and toward him as he’s humiliating you in front of your friends, after you’ve worked so hard?"

"Oh, I’m still pissed! I’m just a kid. It’s not the end of the world!" Then, Tom looks a bit more frightened, somehow smaller. "He’s a bit crazy though."

"He can’t do anything to you, you’re too strong. And he’s not here. This is just you and your feelings, with me. What does that anger want to do to him?"

"I’d punch more. In the face, and head. I’d get the ball and smash his face with it, and kick him in the gut." Tom’s still sitting, talking quietly, but with intensity and clarity. 

"Is there more?"

"I’d just kick the shit out of him." He’s staring into middle distance, moving his fists slowly. Then he stops and relaxes.

"What does he look like? When you look into his eyes?"

"He’s pretty messed up, bleeding. He’s cowering, weak."

"How do you feel right now?"

"Triumphant! I’m sitting straight and strong. And I feel…clear, you know?"

"That’s so great to feel this triumph and strength. And look at his eyes. What do you see in his face?"

"He’s sorry. He knows he’s out of control. He’s telling me he’s sorry." His eyes are softened, a little downcast and moist. 

"What do you feel now?"

"I’m sorry too. He was doing his best. His dad was a tyrant. I want to wipe the blood off his face." He sobs a couple of times, chest heaving. He seems relaxed and very present and looks at me a long while. "You know he drove me so hard. I wanted to do other things than football. It was so important to him. I tried so hard to be perfect for him. I trained and trained. He’d make me run with him, and I’d beat myself up if I wasn’t fast enough. I’ve been so hard on myself, trying to be perfect for him. I hated him for that. I was so angry with him." He tells me how much he missed out on, trying to be perfect.

"How do you feel now, to have experienced that fury at him? To have chosen not to be perfect or beat yourself up, but instead share your feelings here?"

"I feel good…calm. You know, when I broke my elbow, I didn’t know what to do. I felt such a failure."

"You felt a great deal then. It must have been so hard for you."

"It was. But he was just disappointed. I was hurt, but he was mad at me, like I did it to him."

"And the opiates? What did they do for you right then?"

"They were awesome! Perfect. I just didn’t have to think about it much."

"Didn’t have to feel it much."

"Right! I just checked out. I do that."

"You’re not doing that now. You’re really present, really sharing deep feelings with me. What’s that feel like? To do something so different here?"

"A bit weird, but good weird." 

In this vignette, I’m helping Tom past his defenses—blaming himself for messing up, projecting his anger onto his father, and feeling scared—and reaching through his anxiety, which is manageable, to the feelings that he’s had locked up for years. I’m pushing him because I know he needs to go to the deeper emotions. I can’t just permit him to avoid them again—that’s the whole problem! Out they tumble—rage, guilt, loss, compassion—with intensity, but without any impulsive action or actual aggression. It’s all happening in his head, and between us, his memories are re-working themselves into a new truth where he’s standing up strong, setting a boundary, hating and loving, wanting to be loved, no longer avoiding. I’m not telling him where to go, just following along with him, paying attention to what he feels, accepting it, deepening it because his feelings are important. The insight just follows.

In the next session, he tells me he expressed some annoyance at his girlfriend. She can tease him a bit in public, pout a little, act disappointed. She listened, and when she said she was sorry, he knew she meant it. They feel closer now. I see him every month or so for a year, and each time we get into his feelings fast, and he continues to grow, taking up running, moving in with his girlfriend, finding a career he’s proud of. He stays sober.  

People can be stuck in patterns that made the drug use so attractive, so compelling, even when they aren’t using—dry drunks. Relapse is always round the corner for these patients because they continue to live shadowy half-lives, avoidant of their feelings, distant from others, and dishonest with themselves. They haven’t been shown how to feel and share, and they don’t expect to be heard. By using these techniques, daring to go deep, you can re-work memory, and have a corrective emotional experience. The therapy has to build security through titrating the anxiety that always accompanies emotional breakthroughs, just as foam and roar precede a wave. Sessions like these carve a new transformational path, one that is so much more compelling and vital than the drudgery of addiction. It’s intoxicating.

Mark Green, MD, did his psychiatry residency and then addictions fellowship at the Payne Whitney Clinic, Cornell Medical Center, and research in the neurobiology of addictions at Rockefeller University. He is dually-boarded in both general psychiatry and addictions and has been on Faculty at Cornell, Vermont and Harvard Universities. Dr. Green has worked in and directed dual disorders, opioid treatment and pain programs. He founded Psych Garden in Belmont, MA, where his team provides expert psychotherapies and psychopharmacology to patients and families with addictions and psychiatric disorders, utilizing the evidence base in an always personal and flexible way.

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Mark Green, MD, did his psychiatry residency and then addictions fellowship at the Payne Whitney Clinic, Cornell Medical Center, and research in the neurobiology of addictions at Rockefeller University. He is dually-boarded in both general psychiatry and addictions and has been on Faculty at Cornell, Vermont and Harvard Universities. Dr. Green has worked in and directed dual disorders, opioid treatment and pain programs. He founded Psych Garden in Belmont, MA, where his team provides expert psychotherapies and psychopharmacology to patients and families with addictions and psychiatric disorders, utilizing the evidence base in an always personal and flexible way. You can find him on Linkedin and Twitter.

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