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Articles by David H Jacobs Ph.D

Ambivalence in Addiction Treatment

Does a person need therapy or treatment to stop doing something if he 100% does not want to do that something? The intuitive answer would seem to be NO, which takes us directly to the issue of ambivalence.

The person who comes for addiction treatment is in the position of trying to say goodbye to the pros of using. If the pros were not substantial and important to the person he would have already quit or cut down and he would not be in treatment. In this regard it is pertinent to point out that most of the people I see have not sought out addiction treatment entirely on their own initiative. In other words, minus some crisis involving other people who in one way or another insist on treatment most would not become involved with treatment. So the initial picture is usually one of ambivalence on the part of the client in treatment. I am suggesting that ambivalence is par for the course. I don’t see people who are not ambivalent’”they quit on their own.

The pros of using are so important that it is commonplace for people in treatment to report they have tried over time to learn from their experience so they can use without using getting out of control’”in other words, use in a manner that does not run up a big bill of negative consequences. Few people at the start of treatment say they have no interest or desire to use. I routinely hear clients with long -term drinking problems say they hope that after a period of abstinence they can learn to drink moderately. The prospect of just giving up the pros is not appealing.

Discussing the pros of drug use (or some other form of addiction) usefully leads to discussing what about living is so difficult for the person. Drug use after all is for the purpose of making life more bearable, livable, enjoyable, even if it simultaneously creates problems in living. People don’t persist in practices that they experience as more harmful than helpful all things considered. How a person lives is akin to what is said about being a politician: it’s about doing what is actually possible all things considered rather than doing what is best from an abstract perspective.

When a person opens up about how and why he uses drugs (or whatever) it becomes clear that drug use is the best solution to the challenges of living he can muster on his own. A person who is relying on drugs to cope with the challenges of living is in effect announcing that he has been injured in some important ways by his experiences in life. Some people find a way for a long time to blend serious drug use or some other form of addiction with normal appearances and occupational/financial success (after all, who is going to those very expensive residential treatment facilities in Malibu and other locations?). It usually takes some kind of crisis that involves other people who will not allow the old status quo to reassert itself to push the addict into treatment. At least that’s the usual story with people I see.

As soon as the point is grasped that the addict is using drugs or another habit to make his best adaptation to the challenges of living, it is apparent that ambivalence is going to be an important feature of the treatment situation. Even if the person can see that his usual modus operandi is not sustainable, he has no clear idea at all how he will cope with the challenges of life and squeeze some enjoyment out of life minus drug use or some other habit.

At this juncture I want to make a seemingly obvious but important point. It is easy to lose sight of the fact that the person in question is not a person but a specific person. It is all too easy from the outside to think of much better ways for a person to deal with the challenges of life (than drink excessively, do drugs, watch porn, etc.). What needs emphasis is that the person in question is doing his best with the psychological resources and life lessons at his disposal. If he saw better options that he thought were doable he would already be on some other path. The purpose and aim of addiction treatment is to enable the client to feel differently about options and possibilities in life.

There are opportunities for beneficial experiences and learning in therapy. Therapy that is set-up in a manner that allows freedom to speak without fear of consequences and therapy in which the therapist understands that the only practical way to ameliorate the harm done via important past relationships and social experiences is via a special new relationship in which trust, caring for and about, empathy, patience, respect, understanding, positive regard, etc. are continuously and reliably available. Only direct personal experience of being able to trust, being understood in a caring and empathic manner and so on can make a significant dent in the beliefs, expectations, sentiments, etc. that have rendered relying on drugs or some other habit the best adaptation to living despite the drawbacks and negative consequences.

Some kind of crisis may bring a person into treatment, but over time the person can find a way back to drug use or whatever once the crisis subsides and he is again operating primarily under his own recognizance (e.g., I just spoke to a person who was ‘intervened’ into a famous residential rehab facility. Following his discharge he remained sober for nine months, but over time returned to baseline, thus his presence in my office due to pressure from his wife). The core problem as I see it is that based on life experience the individual trusts drugs or some habit far more than any person to obtain comfort and relief from inner distress (including agitation, restlessness, emptiness, ‘boredom,’ etc. Drugs or porn or whatever are always available, never say No, give without demanding or expecting anything in return, never disappoint or shame or reject or misunderstand or talk back.’ Thus the attraction. The therapeutic relationship has the potential to open the door to renewed interest and hope that human relationships can be safer and more rewarding than earlier life lessons taught.

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