Thursday, 13 November 2014

Working with Addiction : Part One.

This piece is an argument about how to deal with addiction. It contains an account of the main strategies that have been suggested to help clients cope with addictions. It does not accept that Cognitive therapy by itself is the best approach. It firmly sides with an Integrative therapeutic view rather than the strategies of Alcoholics Anonymous. I do not accept the blanket statement, which is at the core of the approach of AA and similar organisations, that "we are powerless in the face of our addictions" and therefore have to call upon the aid of a "higher power" to resist them.

Nor do I think it remotely convincing to claim that the Twelve Steps can be retained but reinterpreted with a personal idea of a "higher power."  The steps clearly imply a beneficent, omnipotent God. At AA meetings, religious ideas often predominate.

At the risk of losing most of my readers early on, I need to say that, although I have religious views of my own, I have worked with non-religious people who have combated their addictions with massive effectiveness by using psychological means, and so I am advocating a psychological rather than religious view of addiction work.

The way in which I have seen people gain control over their addictions is by thinking effectively about the addictions but also about themselves and their entire lives. For an addict, this might seem woefully inadequate and weak. Most have recognised that their behaviour is self-destructive but have not yet stopped it.

The key word above is 'effectively'.

My argument is going to be that the existence of modern technology enables therapists to think about doing addiction work in new ways- ways that bridge the gap between Humanistic, on the one hand, and more cognitive and directive therapies on the other. These can be used in the service of improving the effectiveness of established therapeutic techniques.

There are at least six ways in which the effectiveness of thinking can be enhanced: firstly, it can become more focussed. Secondly, it can make greater use of psychological principles. Thirdly, running alongside the first despite being very different in character, it can be more freely and deeply exploratory. And, fourthly, it can get to the psychological maintaining factors on an emotional level. Fifthly, it can be directed towards greater life satisfaction which can remove much of the motivation to escape. Sixthly, it can put an emphasis on becoming more of an engager and less of an avoider, thereby attacking the denial and ostrich-like behaviour which often characterises the drinker and drug-taker.

If it is possible to maximise the effectiveness of our thinking, and therefore the degree of control we have over our behaviour, then the next question is " What can a therapist do to enable the client to use his or her thinking to improve their lives?" This question takes us into the realm of discussion around how best to do therapy. 

My argument here is that therapy debate has become a university-led fight over paradigms, and that it would be much better to focus debate around different difficulties faced by clients and how best to help them to move forward. Much debate about addiction involves different and competing schools of therapy. For example, cognitive therapists often have a horror of therapist behaviour which departs from their manuals. They stigmatise this as "paradigm drift".  But this is sectarian thinking; on the contrary, it makes sense that, if a focussed way works, and a deep exploratory way works, then combining the two will work at least as well as either of the approaches on their own. And, if the integrative therapist believes in such an approach, it may be particularly powerful. 

One reason why I am convinced of this is because I think that the person who can understand his or her own behaviour on both the micro and the macro level is especially well placed to change it.

If we consider any field of human endeavour, excellence depends on combining the general and the particular, the broad sweep and the vital detail. This is as true of therapy as it is of any other area of human endeavour. A competitive cyclist needs fitness, stamina, motivation and quick reactions but also needs to know the route and watch out for potholes. 

For that reason, I believe in a comprehensive approach to addiction. Firstly, I believe that, as far as alcohol is concerned, the addict usually has a choice between abstinence and cutting down. This is because it seems that something that can be learned can be unlearned, and can be unlearned by the same set of psychological principles that governed the initial acquisition of addiction. These principles, collectively, are known as "learning theory".

Yet, in therapy, the wishes and experience of the client has to be paramount or the therapy will not work. The client may discover, by experience, that cutting down does not seem to be a relevant option, and this may be particularly true of those clients who like a drink and who are also addicted to cocaine. Alcohol interferes with the functioning of the part of the brain which specialises in rational thinking and so, after a few drinks, the strategies and considerations which enable the client to resist cocaine may become unavailable. Yet I have also met clients who drink liberally but abandon cocaine use, so I would not like to be dogmatic about this. My own experience of clients is that cocaine is so physically and psychologically addictive that the addict is not able to return to occasional use but even here I have encountered an exception.

Therapy can most usefully begin by encouraging the client to establish the reality of his or her own addiction. This should be a factual rather than a moral matter, and challenging the client's view of the facts needs to be done, if at all, sparingly and diplomatically or a tendency to retreat into denial could be exarcebated. Nothing could be more unhelpful than the "demon drink" approach. 

At the moment, probably the majority of addiction therapists are themselves former addicts who have been through twelve-step programmes, see themselves as being "in recovery", continue to attend AA or similar meetings, and who use twelve-step methods with their clients.  While it is beyond doubt that these traditions can be incredibly helpful to some clients, I believe that others find them outdated, puritanical, excessively spiritual, and involving the replacement of one addiction with another: an addiction to meetings.

The essence of the early sessions embraces the "motivational interviewing" technique of Miller and Rollnick and the "drinking diary". As part of this, the client is encouraged to record the circumstances in which the craving originated and the associated feelings and thoughts and thereby spot what patterns are occurring. This is a way of introducing one of the most important strands in addiction treatment-namely engaging the client totally in the process of therapy by making use of the client's capacity to think and innovate. This is where what person-centred therapists call " the actualising tendency" comes in. This should not be regarded as the preserve of humanistic therapists alone. D.W. Winnicott noticed this tendency in the people he worked with, calling it the tendency to " grow towards the light". 

Therapists here have the opportunity to exploit the benefits to addiction therapy provided by new technology. 

For example, as part of the Cognitive approach to addiction, clients have been encouraged to produce a "decisional analysis" summing up the advantages and disadvantages of their own addictive behaviour. By keeping this on their mobile phones, it is possible for clients to keep this  continually under review, to keep on modifying it, to keep it continuously relevant and continuously accessible. The benefit of this to the client is that it becomes interwoven with his or her daily life instead gf being an unchanging piece of paper kept separate from it.

In the past, it was never even remotely practical to keep a drinking diary using paper and pen during a drinking session but now that it is perfectly normal and acceptable to consult your mobile phone during a conversation, it has now become possible to make a "real time" record of your drinking while you are doing it. You can also use Excel to make a tabular record of your progress, so you can record the pattern of your drinking. For emphasis, it is possible to colour code this, so that you can see how many "red" days there have been in comparison with "green days". Moreover, you can record a motivating talk to yourself in relation to your drinking; as people know their own psychology well, this can be very effective. The very act of writing this talk, with its drafting and even re-drafting, can be very effective in strengthening the motivation of the client. The client can also record messages to themselves encouraging some degree of restraint at crucial points during hazardous situations-say, after drinking five pints during an evening with an old friend; this might be a good moment to tell yourself that you have enjoyed a relaxing and pleasant evening, and, if you stop now, you will have a good day tomorrow. You can also keep on your mobile phone a set of encouraging images.
For example, clients often do not decide to give up an addiction while keeping the rest of their lives unchanged. Indeed, there is some evidence that continuing to resist an addiction is most likely to achieve long term success if you also establish a more rewarding life for yourself. You can use your mobile phone to record and store motivating images. For example, a client who loved cycling could use an image of a cyclist - or a personal photo- which reminds the client that, if he or she goes home now, there will be an opportunity to go cycling tomorrow instead of staying in bed with a hangover. A picture of a partner or child might remind a client of a motivation to keep drinking within reasonable bounds. At the same time, you can also store the written word on a phone and this, crucially, could include reminders about forgiving yourself for your imperfections and failings. Clients can also be asked to give a presentation to the therapist, using PowerPoint software, on the physiology and neurobiology of addiction. Google is a blessing in this regard; there is so much information available. I have found that clients are good at coming up with strategies for using technology, so the therapist can harness the client's creativity, only adding to the ideas in a mutual brainstorming session.

If the client wants to cut down on an addiction, then they may need encouragement in certain skills. Resisting addictions is quite a complicated business, and so it is unreasonable to expect the client to "re-invent the wheel". I think that some person-centred therapists have such a horror of being thought of as experts that they set themselves up, in practice, as enemies of knowledge. But the therapist does not have to substitute a pedagogical role for a therapeutic one. The beauty of Google and other search engines is that the therapist does not have to train the client in assertiveness skills which might help a client whose "friend" is bemoaning the client's reluctance to drink alcohol. The client can look up assertiveness techniques and can apply them to his or her own situation.

There is no limit whatsoever to the usefulness of new technology in addiction work. Clients can be encouraged to make their own lists of the reasons they give themselves for drinking, alongside an all-important list of the fallacies involved and of alternative behaviours which could be substituted. A client who rewards himself for getting through a hard day by buying himself a bottle of whiskey could substitute an alternative treat- downloading a movie or whatever.

The learning theory approach involves being aware of addiction as a behaviour learned in response to a variety of cues. For example, getting off a train may be associated with heading for the pub nearest to the station. Awareness of this helps the client to become aware of the link and make a new decision to break it. These cues may be very numerous but unconscious, such as the beginning of the news on the television; quite clearly, certain people and situations can act as the stimulus in a stimulus-response chain. Once these have been identified, ways of coping with difficult situations can be adopted. The anticipation of difficulties helps the client to acknowledge and cope with them.

By encouraging the client to look forward and anticipate, the therapist is tackling two mental habits which can distinguish addicts from non-addicts. One is a tendency to think in the short term. The cocaine addict, for example, thinks of the high, which may last for hours rather than the comedown which may consume days.

The second is a tendency to engage in ostrich-like behaviours. Psychologists have identified the categories of "engagers" and "avoiders", addicts tending towards membership of the second group. Addictions function as tools of avoidance. Hence, if addicts realise that they can find solutions to their problems, they have less incentive to use an addiction to avoid them. (Continued in Part Two)