by Scott Kellogg and Andrew Tatarsky
Many addicts have mental health problems, and all have complex reasons for using substances. In order to effectively address both the addiction and what drives it, providers require training and skills in psychotherapy.
The recent suicide of country singer Mindy McCready brings the death toll of patients who were treated on Celebrity Rehab to five. On Monday, Fix columnist Maia Szalavitz questioned the effectiveness and ethics of Dr. Drew’s specific approach. But McCready’s death also calls for us to reflect more generally on the nature of addiction and its treatment. In addition, the loss of these five entertainers and public figures speaks to how devastating both addiction and mental illness remain as well as how our society conceives of addiction.
The DSM-IV-TR and the upcoming revision, DSM-V, due out in May, define addictions to alcohol and drugs as psychiatric disorders. Nora Volkow, MD, the director of the National Institute on Drug Abuse, agrees, saying, “We need to first recognize that drug addiction is a mental illness.” This focus on mental health also conforms to research increasingly revealing the many ways that addiction is a brain disease.
By contrast, Alcoholics Anonymous has been centred on a model of alcoholism established before the development of this kind of disease paradigm, and it has not espoused clinically complex models of psychological motivation. As AA cofounder Dr. Bob told attendees at a 1950 AA convention: “There are two or three things that flashed into my mind on which it would be fitting to lay a little emphasis; one is the simplicity of our program. Let’s not louse it up with Freudian complexes and things that are interesting to the scientific mind, but have very little to do with our actual AA work.”
Our own approach to addiction, which we call Integrative Addiction Psychotherapy, is based on the following assumptions:
• Addictions are psychiatric/mental health disorders.
• Many, if not most, addicts also have additional psychiatric issues such as PTSD, depression, anxiety disorders, psychosis, ADHD, and various personality disorders.
• With or without a diagnosable condition, people use substances for reasons that need to be respected and addressed.
• The treatment of addictions require professionals trained in mental health, skilled in psychotherapy, knowledgeable about the full range of psychological treatments, and fluent in the use of both addiction and psychiatric medications. Passion and dedication are important, but they do not make up for deep skill and knowledge.
What does an Integrative Addiction Psychotherapy based on these assumptions look like? Building on themes that were addressed in a previous Fix article and a related article on addiction treatment reform, we believe there are seven essential components:
1. Individual Psychotherapy: Each patient is unique and treatment must be individualized to address their specific needs, history, biology, pain, dreams and desires. While group experiences may be very powerful, even life changing, the integrity and depth of the individual psychotherapy session remains a uniquely curative experience — and the cornerstone of this approach.
2. Therapeutic Alliance: The connection between the patient and the therapist is of vital importance as it is at the heart of treatment. Good therapists will demonstrate love for their patients and will work with authenticity, optimism, courage and determination. Research in both addiction treatment and psychotherapy show the positive benefits of patients having a good relationship with their therapists.
3. Drug Use Is Meaningful: As noted earlier, people use substances for complex and deep-seated reasons that may need to be addressed before the individual will be willing to make changes in their use. Drugs may serve as a pathway to pleasure, as a way to reduce inner pain and suffering, as a method for coping with medical problems, as a vehicle for making and affirming social connection, and as a response to social oppression and poverty.
4. Multiplicity of Self: People who use drugs often have conflicting motivational forces at work — some of which support the continued use, others that fight for change. The motivations for change might include concerns about the family, anxiety related to economic or prestige threats, existential or spiritual concerns, health issues and legal problems. This inner conflict can be usefully re-conceptualized as a community of voices, modes, selves or parts. In this way, each of these energies can be respected and given a chance to speak, and dialogues can be created among the different parts to address their needs and desires.
5. Strengthening the Inner Leader: Identifying, connecting with and empowering the Inner Leader — sometimes called the healthy adult mode or the strong and healthy ego — can work to rebalance the inner forces. The individual can then make positive connections with others and take assertive, effective and meaningful action in the world. The Inner Leader of addicted patients is often underdeveloped or severely damaged, so strengthening it will remain an ongoing concern. To be clear, the healthy mode will be distinguished by its use of existential language such as “I want,” “I am deciding to,” “I am choosing to,” “I will,” “I say yes,” and “I say no” — rather than the use of phrases like “I have to,” “I need to,” and “I should.”
6. Working on Two Dimensions: Complex models of treatment, like Integrated Harm Reduction Psychotherapy, require therapists to work on two dimensions: both the use itself and the underlying pain and desires that drive it. Sometimes one will take precedence; sometimes both need to be addressed concurrently. Given this, it can be helpful to conceive of the work as involving both Horizontal and Vertical interventions.
Horizontal Interventions are techniques and strategies specifically focused on such issues as safer use, reduced use, moderation, nonaddictive use and abstinence, including Harm Reduction/Substance Use Management, Relapse Prevention and Contingency Management. The goal is to empower the patient to be able to control their use in a way that makes sense for them. For many, if not most, this will ultimately be abstinence.
Vertical Interventions are those involved in treating the patient’s pain and underlying psychopathology. Addicts may suffer from problems connected to the past (trauma, grief and moral failure), the present (depression, anxiety disorders, lack of assertiveness and personality disorders) or the future (life decisions, identity creation, the project of recovery and the need to embark on the Hero’s Journey). The therapist will want to be able to skillfully draw upon the full range of psychotherapeutic techniques to help the patient make connections, restructure cognitions, face feared experiences, work through traumas, mitigate the impact of the inner critic, claim power, clarify values, take heroic action, and learn to meditate and self-soothe.
7. Identity Transformation: While a great deal of addiction treatment is, understandably, focused on the present and the near future, long-term recovery depends on the ability of the individual to create and maintain identities that are viable, meaningful and reinforcing. The Addict Identity, which is central during active addiction, must be replaced with identities based on some connection to family, work, recovery, spirituality or other activities that provide a self-definition that is incompatible with problematic drug use. (For example, being a father takes precedence over using cocaine.) Most stories of successful recovery and life transformation involve some sort of identity reorganization or creation.
Mindy McCready was ultimately overwhelmed and destroyed by the pain inside of her. While psychiatrists and psychologists made occasional appearances on Celebrity Rehab, none of the major protagonists were mental health providers or had extensive formal training in psychotherapy. We believe that Dr. Drew Pinsky cares deeply about his patients and is dedicated to helping them achieve healing and recovery; nonetheless, his training is in addiction medicine and, while naturally skilled, he is not a trained psychotherapist.
It is our hope that the leaders and practitioners in our field will embrace the future by working to fully integrate mental health and addiction treatment — both in the therapy we do and in the paradigms we create — so that we can understand and work with the complex interplay that exists between inner suffering and addictive behaviour. Addiction is a mental illness.