Addiction: a search for transformation

During my observations as a psychotherapist in treating patients in various residential settings over the last 18 years, I have come to believe that the roots of addiction are common and universal. By thinking psychologically and using the wealth of psychological literature available, we are able to start to tease out and articulate the inner world of the addict in order to both understand these roots and to facilitate recovery.

The roots of addiction

Regardless of the presenting dependency, whether alcohol, gambling, food restriction or purgation, drugs, love, or sex, the main features of addiction are obsession and compulsion, focused around an object or behaviour which, it is believed, will somehow bring transformation of the person’s inner world. When I ask patients to try and articulate the experiences of transformation they seek via these objects and behaviours, they invariably include some of the following: self-acceptance, self-forgetting, wanting wholeness, transcendence of the everyday, love, feeling expanded, feeling complete, feeling good, confidence, security.

Christopher Bollas(1) has argued that the search for transformation of self-experience lies at the heart of ‘object relations’. Object relations theory describes the process of mental development as we grow in relation to others in our world and our internalised images of these others. Object relationships are initially formed during early interactions within the family.

‘The search for transformation and for the transformational object is perhaps the most pervasive [object relationship], and I want to emphasise that this search arises not out of desire per se, or primarily out of craving or longing. It arises from the person’s certainty that the object will deliver transformation’. - C. Bollas 1987, p.27.

Such transformative experiences are deeply desired and universal to all human beings. Unfortunately, for those suffering from active addiction, the legitimate quest for transformation is usurped by the ‘addictive self’.

The addictive self

I am suggesting that the ‘addictive self’ forms as a result of early developmental disturbances and traumas. This self has a strong impulse, in character and behaviour, to unhealthily merge with soothing experiences, along with a disturbed and distorted way of relating to both self and other. There is never, in my experience, a key trigger for the formation of this inner identity, but rather a series of failures on the part of early caregivers in an individual’s development to provide what Donald Winnicott(2) calls a ‘holding environment’. Failures in the holding environment lead to a failure of emotional connectedness with external objects (i.e. mother and father), with the infant becoming utterly isolated. The ‘false (addictive) self’ forms as a way to mediate the loss of the true self, which remains hidden and protected in the unconscious. The false self has features of compliance and adaptation, and fluctuates in response to environmental demands.

The experience of the false self is often articulated by clients in terms of feelings of emptiness, abandonment, loss, separation, self-loathing, self-betrayal, guilt, shame, low self-esteem, isolation and alienation.

In my experience of working with chemically dependent patients, they do indeed offer the false, adapted self as a proxy for the true self. Moreover, this movement within the psyche leaves the individual vulnerable to soothing opportunities, should they come along (e.g. in the form of alcohol, refined sugar, exercise, sex, work, or drugs). These opportunities invariably involve objects outside the self, which can be taken in and ingested to transform the emptiness and associated experiences of the false self. The vulnerability to soothing opportunities leads, I believe, to the formation of the ‘addictive self’.

Encounter with the addictive self

Therapists will invariably encounter the addictive selves of clients, which will still be operative even without access to substances. Group work is the norm in most clinics these days, and since such groups can seem very threatening to patients, at least initially, the group process can often lead to amplification of client defences.

Expectations of residential treatment are often high, with patients expected to become authentic, challenging, honest, supportive, insightful, emotionally literate, able to display their anger and grief, stay open and vulnerable and able to fully disclose. With a residential treatment cycle of 28 days in primary care, the time to implement such a wide remit is obviously limited and invariably, with this sort of pressure, the team can take a few knocks from the defensive group mindset of rationalisation, justification and denial as therapists come into contact with the addictive selves of the participants.

The usual defensive manoeuvres of the unconscious as a therapist attempts to call out the true self are well known, and usually along the lines of aggression, hostility, passive anger, rage, inflation, irreverence, and undermining, devaluing and deskilling of professionals who are there to help. Inevitably these attacks are unconscious and will be a challenge for practitioners to dissolve.

Encounter with the true self

When therapists speak of the true or authentic self, I imagine we concur that this deeper identity is formed in line with the perennial and universal qualities of kindness, gratitude, appreciation, love, joy, acceptance, compassion, generosity, forgiveness, serenity, open-heartedness, sincerity, creativity, vulnerability, wisdom, intuition and humour. These represent a refined version of the longed-for transformation that the addictive self tries to articulate via their chosen object of change (i.e. alcohol, drugs, etc).

In creating the optimum conditions for these positive qualities to grow and flourish in the treatment cycle, we can do no better than incorporate the work of Irvin Yalom(3). Yalom’s work with groups is considered groundbreaking, and colleagues new to the field would do well to have a copy of his group worker’s bible The theory and practice of group psychotherapy. I have found no better master of the art, apart from possibly Jarlath Benson(4) in the UK.

Yalom’s key to the functioning of a successful group is the establishment of a number of therapeutic factors:

• The instillation of hope: the therapist reinforces positive expectations, challenges negative mindsets about group therapy, and provides statements about the efficacy of the healing potential of the group context.

• Universality: the therapist challenges the notion that the patient is alone with the negative thoughts and beliefs they have developed in addiction, and works towards overcoming the sense of isolation and unique suffering.

• Imparting information (not to be confused with advice-giving, or direct guidance, which patients report as of little benefit in post-treatment evaluations): the provision of explanations and clarifications of the group process as it unfolds in the here-and-now, thereby reducing the anxieties that patients may experience.

• Altruism: the therapist encourages patients to offer support, reassurance and insights to each other, in the hope of evoking empathy between members.

• The corrective recapitulation of the primary family group. Patients are apt to recreate historical ways of relating, based on qualities they were exposed to in their family of origin. Family tensions need to be relived correctively, in that patients are encouraged to challenge the family structures as they are recreated and become visible within the group in the here-and-now. The very act of challenging deep-seated mindsets about the way we can be with ourselves and others provides valuable insights into unhelpful limitations that may no longer serve us.

• Development of socialising techniques: the therapist encourages patients to become more helpful and responsive to others by being less judgemental and reactive, and more open and honest with themselves and other group members.

• Imitative behaviour: the therapist models to the group patterns of communication and behaviours that reflect openness, receptivity, honesty, congruency, self-disclosure, kindness and care. Group members can also been seen to learn from more senior members of the group. 

• Interpersonal learning: the therapist teaches the group that addictions (and indeed mental illness) often emanate from disturbed and distorted interpersonal relationships. The group serves to consensually validate the modification of these disturbances through more harmonious and life-affirming ways of relating.

• Group cohesiveness: by self-disclosure of their inner world, patients come to believe that they are not alone, while the group’s accepting individual members in a positive and non-judgemental way validates the individual and leads to a positive and cohesive group experience.

• Catharsis: the open expression of emotion and what is experienced as most authentic by patients is encouraged by the therapist and senior group members. This, in turn, encourages group cohesiveness and normalises the expression of emotion.

• Existential factors: the therapist helps patients to understand that life at times is unfair and unjust; that there is no escape from some of life’s pain and indeed death; and that no matter how close we believe we are to someone, we all ultimately face life alone. The individual is ultimately responsible for how life is lived, and we all suffer our choice.

While therapy is precisely the work of building ground for these therapeutic factors, the focus of the here-and-now transaction can provide exceptional therapeutic leverage for the therapist who can master the technique. For example, consider the following: client A delivers a long monologue concerning a story about his childhood. There is no obvious emotional effect within either the client or other group members, or within the therapist and when the client has finished, another client may tell a story about their childhood, with a similar outcome. Those familiar with group work will recognise this process of delivering content, and taking turns, without any felt contact with self or other.

The therapist who is familiar with working in the here-and-now may ask the group if they feel closer or further away from client A after he has told his story. There are three possible answers: closer, further apart and no different. At this point, the here-and-now is fully activated, and one can ask other group members to report their closeness to client A, and, indeed, client A can then comment on the responses of the here-and-now feedback, generating still more real-time transactions. With the help of the therapist, patients are encouraged to explore the quality of the relationship dynamics within the group; and  continuingly attending to the here-and-now exchanges within the group often reveals what needs attention if patients are to heal and grow emotionally and psychologically.

The here-and-now transaction is, in my experience, truly the royal road to the deeper identity of the true self, in both the group setting and the one-to-one context. If the therapist can master this technique, they will be able to witness the transformation of the addictive self as it aligns itself and surrenders to the deeper experience of the true self. The positive qualities of the true self then become available for further development of our essential human nature, with an associated freedom from the devastating consequences of active addiction.

In residential care, a therapist has 28 days to help facilitate change for patients; the work is very challenging, and there is always a sense of beginnings. The way to establish group therapeutic factors that will facilitate change is for the therapist to become a teacher, in that they model for the group what change looks like. To be truly effective, the therapist needs to model authenticity, empathy, compassion, joy, humility, appreciation, kindness, gratitude, and love – so effectiveness really comes down to the therapist’s own willingness and skill to engage with these perennial qualities, which lie latent and underdeveloped within the patient, and indeed within the therapist.

The effective therapist will consciously foster the optimum conditions for change via the therapeutic factors within the context of the group. This organically leads patients towards a way of being in the world that is not dependent on alcohol or drugs, etc, but based instead on purpose, value and meaning. Patients then are able to return to living more fully in the world, with a deeper sense of identity that is informed by the true self, rather than the addictive self, with its disturbed and distorted way of relating.

References:

(1) Bollas C. The shadow of the object. London: Free Association Books; 1987.

(2) Winnicott D. The maturational process and the facilitating environment. Karnac Books; 1990.

(3) Yalom I. Theory and practice of group psychotherapy, 4th ed. New York, NY: Basic Books; 1995.

(4) Benson J. Working more creatively with groups. Routledge; New edition; 1991.