Real World Clinical Blog: Rethinking Addiction Treatment

by Dr. Danna Bodenheimer, LCSW, author of Real World Clinical Social Work: Find Your Voice and Find Your Way  

     Even if you don’t work in a specifically designated addiction treatment setting, as a social worker, you surely interface with addiction. While we think of addiction as most commonly associated with substance or alcohol abuse, addiction is pervasive and comes in many forms. Some people are addicted to sex, gambling, or food. We are all addicted to our phones, social media, and the little tingle of a “like.” The tendency to think of those who have addictions as distinct from “us” is one of the central ways in which we become detached from our clients. There are many other ways we remain detached from our most vulnerable, addicted clients, heavily worthy of reconsideration and reconceptualization.

     While we are steadily dedicated to the destigmatization of mental illness, drug and alcohol addiction falls outside of our efforts. With no clear research or supporting evidence, our thinking about addiction is guided by forces that only lead to increased isolation of this treatment population. Living in America leads us to think about people who have addictions as individuals with moral failings that range from plain sin to full on criminality. These individuals are often punished in their treatment settings or in jail. Either way, the biases that we hold against clients with addictions are not serving to improve the epidemic of substance abuse.

Myths About People With Addictions

  There are myths about people with addictions that seem to be widely shared.

• First, it is almost universally believed that they are manipulative and drug seeking. We believe that most operate in search of their next fix and have the capacity to do almost anything to accomplish this fix.
• Second, we subscribe to the notion that they are inherently amoral, selfish, and solely interested in caring for themselves.
• We also lean toward overestimating their capacity for destructive behavior, believing that they are capable of theft, abusive behavior toward others, or destruction of property.
• Perhaps most insidiously, we believe that many people who are addicted are making a choice to continue to act in ways that perpetuate their illness, not fully recognizing the powerful role that physiology plays in sustaining addiction.

Myths About Addiction Treatment

     There are several myths that are almost unconsciously subscribed to in the treatment of clients with addictive disorders. These are the most pervasive:

• The only way that people with addictions get better is through the provision of “tough love,” which is typically enacted in the form of just plain toughness.
• Yelling at clients with addictions works.
• They need strict rules in their treatment in order to manage their inherently manipulative behavior.
• Most acts of generosity toward these individuals are enabling, and we, as treatment providers, are incredibly susceptible to enabling our clients.
• We are often blind to our clients’ manipulative behaviors.
• A full blown intervention is typically required for someone to get serious about treatment.
• Drugs cannot help clients get off of drugs.
• We can never see our clients when they are high; this gives them the wrong message.
• People with addictions cannot have loving relationships.
• The only real way for a client to ultimately get better is through embracing the 12 steps.
• Only those recovering from addictions can provide addiction treatment.

Possible Points of Reconsideration

     What is so powerfully compelling about many of these myths is that, while we may subscribe to them, they actually feel counterintuitive. We often find ourselves following treatment guidelines that may feel cruel, withholding, or just plain uniform as opposed to appropriately idiosyncratic.

     For the most part, people become addicted in an effort to self soothe. Whether the self-soothing is to manage physical pain - often originating from a prescription from an actual medical doctor to manage an early childhood trauma - addiction is born out of an inability to tolerate vulnerability, disappointment, or the sequelae of trauma. Many have unbearable internal worlds and will do what they can to flee their own psyches. Others have developed tremendous numbness and use substances to access their own psychic worlds. Often, addiction needs to be medically managed before being psychologically managed, in order to calm the body’s intense physical suffering and withdrawal.  

     When physically balanced, through medicine, the psyche of the person with an addiction comes into view. This view allows us to see that they often have fragile egos that are only sent into deeper fragmentation when faced with tough love and treatment that withholds. Addicted people, although often appearing unboundaried, are simply trying to manage what feels internally chaotic. While boundaries are extremely important when working with them, it is not because the client will always take advantage of the clinician. Instead, it is because they are often of a psychological age that is far younger than their chronological age, and the provision of boundaries serves to contain and maturate the person who is addicted.

     People with addictions are also often incredibly loving and feel intense feelings of love for the people in their lives. The deeper issue is that they hate themselves and feel as if they ought to erase themselves, through substance abuse, to make the lives of their loved ones more manageable. While many of their behaviors seem selfish, in their minds, their choices often feel like the most generous option. Instead of crying to a mother or father, or asking for help from a sister or brother, they will turn their emotional needs inward - leaving them with demanding desperation that needs to be managed somehow.

     Also important to note is that negative consequences do not have a particularly remarkable impact on the psyche of a person who has an addiction. Of course, if negative consequences worked, like the many that are disseminated in treatment settings, the clients would have stopped using quite a while ago. Instead, they feel subhuman, leaving them desperately dehydrated for self-respect. The provision of respect, tenderness, and warmth actually soothes many of the clinical needs of these clients.

     Because so many people with addictions have had significant early attachment ruptures, our work actually needs to shift into the realm of tender, steady attachment. When we treat our clients punitively, which happens in many settings (i.e., withholding cigarettes, phone calls, social privileges), we activate their feelings of rejection. It is precisely these feelings of rejection that underlie most powerful triggers to use. Essentially, they live in unending double helixes of shame. When our treatment choices get hooked into these shame spirals, like staging interventions, asking clients to repetitively and publicly share their stories, we send our clients further down paths of panic and isolation.

     Addiction work is truly trauma work. Trauma work requires deep attunement; recognition of developmental capacity and limitations; and steady, vigorous attention to the relationship. Because ultimately, it is the internalization of relationships that finally offsets the need for the self-soothing that substances provide. Often, the only chance for this type of relationship occurs in treatment. We must capitalize on the potential of this corrective experience rather than subscribe to treatment doctrine that can be experienced as counterintuitive, counterproductive, and hurtful.

Dr. Danna R. Bodenheimer, LCSW, is in private practice at Walnut Psychotherapy Center in Philadelphia, PA, and teaches at Bryn Mawr College Graduate School of Social Work and Social Research. She provides more of her clinical perspective and tips for developing clinicians in her book, Real World Clinical Social Work: Find Your Voice and Find Your Way.