By Philip Chanin, Ed.D., ABPP, CGP

Board Certified Clinical Psychologist

Assistant Clinical Professor, Department of Psychiatry

Vanderbilt University Medical Center

www.drphilchanin.com

philchanin@gmail.com

Addressing Addictive Behaviors as the #1 Focus of Psychotherapy

“Like Dante and Virgil, standing together on the broad plain of Hell, looking down into the concentric circles of the Inferno, Jeffrey Robinson and I perch on the rim of his personal wasteland.  We speak, almost abstractly, like two merchants weighing an object for purchase, of the pros and cons of his possible descent, the hardest work of his life.  Jeffrey and I are at one of the critical junctures in healing the depressed man’s relationship to himself—the moment he decides to stop his flight and face his own condition.  Once a man resolves to take up his hero’s journey, real therapy can begin.  Our descent occurs in three phases.  First, the addictive defenses must stop.  Then, the dysfunctional patterns in the man’s relationship to himself must be attended to.  Finally, buried early trauma must reemerge and, as much as possible, be released.” (I Don’t Want to Talk About It by Terrence Real, pp. 269-270)

“Whenever a man turns to an external prop for self-esteem regulation, he is involved in the defensive structures of covert depression.  Narcissus at the well (transfixed by his image) is an addict.  For simplicity’s sake, I label dependency on any self-esteem ‘dialysis machine’ as addictive dependency…Just about anything can be used as an addictive defense—spending, food, work, achievement, exercise, computer games…The cure for the addictive defenses is simple in theory, miserable to experience.  All one need do to stop such defenses is decide to stop them—then, with ample support, withstand the withdrawal.” (pp. 270-271)

Real draws upon the work of others in the field of addictions, including “Edward Khantzian, the father of the self-medication hypothesis, (who) speaks of addictions as attempts to ‘correct’ for flaws in the user’s ego capacities…Khantzian and others currently writing on the psychology of addiction speak of substance abuse as a desperate strategy for dealing with self ‘dysregulation.’  Khantzian’s research on both alcoholics and drug abusers led him to focus on four cardinal areas of dysregulation:  difficulty in maintaining healthy self-esteem; difficulty in regulating one’s feelings; difficulty in exercising self-care; and difficulty in sustaining connection to others…The damage to self that Khantzian describes can be summed up as damage in relatedness.” (p. 276)

“We shall get rid of that terrible sense of isolation we’ve always had.  Almost without exception, alcoholics are tortured by loneliness.  Even before our drinking got bad and people began to cut us off, nearly all of us suffered the feeling that we didn’t quite belong.  Either we were shy, and dared not draw near others, or we were apt to be noisy good fellows craving attention and companionship, but never getting it—a least to our way of thinking.  There was always that mysterious barrier we could neither surmount not understand.”  (Twelve Steps and Twelve Traditions, p. 57)

In the late 1980’s, I spent four years working as a staff psychologist and then Chief of Psychology at a 134-bed alcohol and drug rehabilitation hospital, Spofford Hall, on Spofford Lake, midway between Brattleboro, VT and Keene, NH.  I learned a great deal about addiction treatment, from the patients and also from the staff, many of whom were in recovery.  Now, working in my private practice in Nashville, I see many patients who are struggling with addiction.  I draw upon what I learned at Spofford Hall.

For example, in working with an addicted patient now, I might suggest to him that often an alcoholic is a person with a high stress personality, who gets himself into high stress situations, creating a desperate need for relief.  Often alcohol or a drug will provide that relief. To another patient, who drinks out of boredom, I might say, “Alcoholics often struggle with leisure time.”

Character Defects

In diagnosing alcoholism or drug addiction, I often use an instrument called the SASSI, which stands for Substance Abuse Subtle Screening Inventory.  The SASSI manual identifies common “character defects” of the alcoholic as “needing to be recognized, having a desire to be in charge and do things his way, tending to be resentful, and prone to workaholism and a sense of being driven.” (p. 5-8).  Recently, one of my recovering patients attended a weekend Alcoholic Anonymous (AA) retreat.  He shared with me some reflections by one of the speakers at the retreat, who said that often alcoholics are known to be “unsatisfiable, fault finding, opinionated, easily frustrated, always in a hurry, and hating hearing the word ‘No.’”

The AA recovery book quoted above, Twelve Steps and Twelve Traditions, also identifies a variety of alcoholic “character defects.”  The authors write, “Defective relations with other human beings have nearly always been the immediate cause of our woes, including our alcoholism…calm, thoughtful reflection upon personal relations can deepen our insight.  We can go beyond those things which were superficially wrong with us, to see those flaws which were basic, flaws which sometimes were responsible for the whole pattern of our lives.”  (p. 80)

Resources for Recovery

Sometimes I will suggest to an alcohol or drug abusing patient that s/he contact the Admissions Department at Cumberland Heights, Nashville’s best-known treatment facility, and ask for an evaluation.  If the evaluation suggests significant abuse or addiction, the recommendation is usually a 28-day inpatient stay, or 6-8 weeks of Intensive Outpatient Treatment (IOP), or attending 90 AA meeting in 90 days.

If it’s unclear whether a patient’s alcohol use is a problem, I will advise him or her to restrict their use to a maximum of two drinks in any 24-hour period.  If they are unable to do this, it usually means that they will need to stop drinking entirely.  In this case, I will strongly urge the patient to engage in a recovery program, attending AA meetings and getting a sponsor.  If the patient wants help finding a sponsor, I can suggest several sponsors who are known to me.

Some patients are uncomfortable with AA’s religious approach to recovery and the idea of utilizing God or a Higher Power in recovery.  To these patients I will suggest Buddhist recovery, including Buddhist and Mindfulness-based recovery meetings.  Related books such as Refuge Recovery:  A Buddhist Path to Recovering from Addiction and Recovery Dharma:  A Transformative Guide to Healing Addiction Suffering Through Buddhist Practices and Principles are often very helpful.

My favorite recovery books include Terrence Real’s I Don’t Want to Talk About It, which is quoted above, and two wonderful books by Caroline Knapp, Drinking:  A Love Story, and Pack of Two, about the role her dog played in her recovery.  Another helpful book is We Are the Luckiest:  The Surprising Magic of a Sober Life, by Laura McKowen.  She also has developed an online recovery community with regular online meetings, which have been very helpful for some of my recovering patients.

When I work with patients who have an alcoholic or drug addicted family member, I usually suggest that they attend Al-Anon meetings.  I will share with them an Al-Anon publication entitled “Detachment” which states, “Living with the effects of someone else’s drinking is too devastating for most people to bear without help.”  It also says, “In Al-Anon we learn not to suffer because of the actions or reactions of other people, not to do for others what they could do for themselves, not to manipulate situations so others will eat, go to bed, get up, pay bills, not drink, not to cover up for anyone’s mistakes or misdeeds, not to create a crisis, and not to prevent a crisis if it is in the natural course of events.”

Intervention

Terrence Real, in his book The New Rules of Marriage, writes, “In cases of addiction or of severe verbal abuse, I have often helped families and friends do an ‘intervention’ with a plan for a rehab program in someone’s back pocket, and with sometimes quite severe consequences should the addict or abuser refuse.” (p. 271).   In my work in the substance abuse treatment hospital, often we worked with patients who were there as a result of an intervention.  I remember an Eastern Airlines pilot who had stepped off his airplane and had been ushered into an airport room where fellow employees and his family members conducted an intervention, with a van outside waiting to take him to the treatment facility.

“One day at a time” is a common refrain among recovering alcoholics, who rarely will make statements such as “I’ll never drink again.”  Recovering alcoholics with several decades of sobriety talk often about “gratitude” for how much better their lives are in sobriety.  They might say, for example, if asked how they are doing, despite 20 or 30 years of recovery,

“I’m doing well—I haven’t had a drink today.

Talking with an alcoholic patient who is struggling, I might say, “You have an opportunity to be a ‘high bottom’ alcoholic, in which you get into recovery before you have lost important parts of your life.  Otherwise, you face the prospect of becoming a ‘low bottom’ alcoholic, when you’ve lost your job, your marriage, your children, and your health.”  Psychotherapy with recovering patients includes helping them to develop new relational skills like dealing with their anger more skillfully.  Often there is grief work as they come to terms with their losses.

As stated in Twelve Steps and Twelve Traditions, “We should nevertheless make an accurate and really exhaustive survey of our past life as it has affected other people.  In many instances we shall find that though the harm done others has not been great, the emotional harm we have done ourselves has.  Very deep, sometimes quite forgotten, damaging emotional conflicts persist below the level of consciousness.”  (pp. 79-80). Psychotherapy with addicted patients

needs to explore these emotional conflicts and develop new skills for a sober life.

A Case Study in the Treatment of Marijuana Addiction

Several years ago, I began working with a patient whom I will call David, in his early 40’s, who talked with me about his chronic daily marijuana use.    He said to me, “I’m a very heavy marijuana user—heavier than anyone I know.  Is this cannabis addiction?  Such a fruitful one.  Helpful for my mental state.  Helps me come into the present moment.  I’ve never told my psychiatrist—I’m embarrassed about it.  It seems like a dependence.  I’m embarrassed to be a dependent drug user.  I’m terrified he’d tell me to stop.  It’s scary to think about stopping.  I’ve been a daily marijuana user since I was 20.  When I’m bored, I use it to pass the time.  It would be a good idea if I used it less.”  I then suggested to him that he has used marijuana in part to treat his depression.  He responded, “Without a doubt.  To augment my antidepressant.”

At my suggestion, David read Terrence Real’s book, I Don’t Want to Talk About It.  David said to me, “The book makes me think about how I’m raising my son.  My addiction.  I’ve always known I’ll have to change this.  No question it’s an addiction.  I don’t know if there’s a way I can do this (stop the marijuana use) and not go cold turkey.  I’m looking for resources—ways to guide me through this.  I’m ready to make a change.  I’m not yet ‘scared straight,’ but it’s not sustainable.”  At this point I asked David, “How will you manage your boredom if you’re not high?”  He responded, “Physical activity—golf and yoga.”

David then remarked, “I’m trapped in my own prison, a cycle of my own making.  “Sounds like what in Alcoholics Anonymous (AA) is called ‘terminal uniqueness,’” I suggested.  David responded, “That’s a great descriptive phrase.  It takes two forms.  I’m desperately wanting to be unique, while also wanting to fit in and not be an outcast.  My kneejerk is to do the opposite of what I’m really wanting.”  “So you can be special?”, I asked.  “Yes,” David answered.

David continued, “My life got so much more complicated after I started using drugs.  Depression crept in.  Everything was not okay.”  “So then you were using marijuana to deal with depression?”, I ask.  “Yes,” David answered.  “I used marijuana as a refuge.  It enhanced my leisure activity.  It took me out of my head.  But it doesn’t work that way anymore.  Marijuana has always been bound up with depression.  I may have decided to try it, because I was starting to feel the pain coming into my life.  Inextricably linked to battling depression.”

Psychiatric Consultation for Addictive Behavior

I referred David to the psychiatrist with whom I was working closely at the time, Dr. Mike Reed.  Dr. Reed emailed me his clinical impressions after meeting with David: “Anxiety is more prominent than depression.  His biggest complaint is about his anger which is hard to suppress.  David’s marijuana addiction may well be associated with his problem with anger.  Anger can be linked to the right amygdala in the brain.  Marijuana selectively primarily affects the temporal lobes where the amygdala is located.”

Dr. Reed added, “The lack of vegetative symptoms (lack of energy/apathy/anhedonia) despite the presence of cognitive depressive ideation usually means a person is partially treated with exercise.  David said he feels sure he would have other symptoms of dysthymia (low level depression) if he stopped exercising because he has seen evidence of such in the past.  If adjustments to his current medications do not resolve his symptoms, then I will start David on Prozac, 20 mg each day.  Hopefully with some improvement, especially with the feelings of anger/irritability, David can let go of his marijuana addiction.  He is bothered by the fact that he is an addict.  Psychotherapy is key to all.”  (email communication 9/23/2019)

Psychiatrist Dr. Ben Frock is currently seeing a number of my patients.  Those with alcohol addiction have been greatly helped by the medication naltrexone, which blocks the “high” feeling that makes a patient want to use alcohol.  Recently, I asked Dr. Frock about his thoughts on long term marijuana use.  He wrote to me, “Occasional use (3 to 5 times per month) does not seem to be all that bad for most folks.  The less the better, but mild use is fine for most people.”

Dr. Frock also stated, “When people start using more than this—especially daily—I really see a lot of worsened anxiety over time.  There are many people I see who just aren’t doing well when they are using it regularly and then clearly get better when they slow down.  In particular, I see a lot of anxiety, apathy, and amotivation.  It just seems to trap you in a relatively hypoactive state and people don’t realize it.  People start using more because initially they think it helps with anxiety but over time it becomes the opposite.  There’s a lot of research to back this up at this point.”

Dr. Frock suggested that there are certain conditions when patients should not use marijuana at all.  He wrote, “Situations in which cannabis is a big no-no would be a strong family history of bipolar disorder, and personal or family history of psychosis.  Cannabis is clearly linked to exacerbated psychotic symptoms in the vast majority.  For example, for some patients who have bipolar disorder and are worried about their kids due to inheritability, I tell them the number one thing they should not do is use cannabis at an early age and to be cautious generally.”  (email communication, 2/22/2023)

Summary

In summary, I subscribe to Terrence Real’s belief that patients must first address addictive behaviors before any meaningful positive change in their lives can occur.  Thus, psychotherapists must be knowledgeable about addiction treatment and resources.  Some of my favorite patients have been those in recovery from addiction, partly because they are acquainted with utilizing a spiritual perspective as part of their recovery.  I have also worked with many couples in which one or both partners are engaged in addictive behaviors.  Often their conflicts are much worse when they have both been drinking.  As psychotherapists we need to be alert to the presence of an addiction, and often we need to be firm with patients about the damage this is causing to themselves and their families.