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Articles by David H Jacobs Ph.D

How Does Change Occur in Psychotherapy?

I think it will be helpful to me and to prospective and beginning clients to try to provide an overview of how I think about psychotherapy and discuss a common question: ‘How does change occur in psychotherapy?’
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Make-Believe in the Addiction Treatment Industry

Therapists shouldn’t be in the business of make-believe. There is a great deal of make-believe in the addiction treatment industry. The truth is that giving up your old friend (alcohol or another drug) is going to be a difficult, slow process. You’re going to need a new friend to replace your old friend. The new friend will be a therapist with whom you develop an important relationship over time. Read more

Magical Thinking About Drinking

Most of the people I see who have serious drinking problems express the hope that they can over time acquire the ability to drink in a moderate, controlled manner (drink normally, like other people, etc.). When they have “slips” they frequently say that their intention when they began drinking was to only have one or two, but once they had one or two they kept on going. Despite long experience drinking problematically, and despite serious consequences (which is of course why I am seeing them), the hope, wish, desire, intention remains to draw upon past experience as information and as lessons learned so that drinking can be enjoyed without progressing to excess and bad consequences. Many people find it very difficult to give up the conviction that there must be a way to draw upon experience and lessons learned so as to be able to drink in a moderate and safe manner. The desire to drink normally, to fit in socially with others who are drinking normally, and to be able to enjoy the taste and positive psychological and social benefits of alcohol is very strong. It may seem painfully self-evident from the outside that this person is unable to drink in a safe manner, but from the inside it seems that being able to enjoy alcohol safely is almost within reach and the quest should be pursued. By the time a person is in treatment he may realize that other people feel very negative about his conviction that safe drinking is close to being in reach and he only needs a little more experimentation to get it right, but on the inside he still harbors the hope and belief that he does not really and truly have to swear off alcohol.

What the person with a drinking problem is so loath to give up is the magic elixir properties of alcohol. Some period of abstinence is one thing—to detox, to regain footing in marriage or on the job and so on— but simply eliminating alcohol from living life is quite something else. Alcohol works so well in so many ways: relaxation, positive mood alteration, anti-boredom, anxiety-quelling, a friend that can be turned to and relied upon and never disappoints and is always available and demands nothing in return…Small wonder that the desire to tame the genie in a bottle and the conviction that it CAN be done is clung to so tenaciously.

In short, for some people alcohol is a magic elixir because they have no reliable, viable, practical alternative to drinking for relaxation, positive mood alteration, and so on. This makes drinking more than a way to pleasantly alter one’s psychological state a bit in the right company, at the right time, under the right circumstances. This makes drinking a respite from one’s usual background feeling state, which is such that the individual is strongly motivated to alter it. Drinking makes life livable day by day. This is the highest priority. If you ask a person to raise some other consideration to highest priority you will be disappointed. You see the problem. From the outside frequent intoxication is just bad. From the point of view of the person who uses alcohol to make life bearable there is no higher priority than making life bearable. Why be alive day to day if life is not bearable? Of course there are manifold negative consequences of frequent intoxication. The person with a drinking problem realizes this only too well (denial and minimization notwithstanding). But there seems no practical alternative.

In a previous blog I discussed why a person with a drinking problem does not just drink enough to pleasantly alter her state as opposed to drinking into severe intoxication (with whatever regular and/or haphazard consequences). Why get so drunk? I have given this a lot of thought (and discussed it with many people with drinking problems). I realize that drinking into severe intoxication may not invariably occur on every drinking occasion. Some people drink severely on only some drinking occasions, rather unpredictably. But why does anyone repeatedly drink into severe intoxication, blackouts, etc.? My answer is twofold. First and rather obviously, drinking alters judgment and inhibitory control. Thus sober resolutions tend to become compromised after a certain amount of drinking occurs. Secondly, the person with a serious drinking problem finds the psycho-emotional effects of alcohol a great relief from his sober psycho-emotional state.  The relief offered by a couple of drinks will on certain days (for some people every day) be insufficient. What the person wants on some days or for some people every day is to get far away from her sober psycho-emotional state and to delay returning to it—thus high volume drinking, drinking for extreme intoxication and to stave off sobering up for a substantial time period.

By the time I see a person with a serious drinking problem the effects of drinking too much too often have created consequences that the individual cannot ignore or evade. This usually means that other people that cannot be ignored or evaded have become involved (spouse, parent, employer, the criminal justice system…). It’s at this point—the point of entering treatment, although entering treatment is not the individual’s own idea—that I usually hear the wish expressed to drink in a moderate, controlled manner like other people. This could be construed as denial or minimization, but I want to emphasize for the sake of this discussion that I hear it as an expression of how functionally important alcohol is to the individual in terms of mood alteration and so on.

A straightforward inference from my contention that the problem drinker relies on alcohol to make life bearable is that giving up alcohol is going to be difficult. That would be a correct inference (substitute any addiction or addiction-like behavior here). To the outsider it can seem astonishing how quickly the urge to drink returns after the latest alcohol-induced disaster. I have often been just so astonished. Over time I have come to recognize that the memory of how bad it was fades as the desire for relief builds. As the desire for relief grows in strength so does the conviction/wish that drinking can be indulged in without it getting out of hand. Success on one or more occasions strengthens the conviction/wish. We’re talking about a vicious circle.

The real focus of therapy is the chronic psychic pain and the taken for granted feeling/conviction that one is alone with it. Barring emergency circumstances, the therapist must live with the fact that non-reliance on alcohol is the goal of therapy, not the prerequisite or corequisite for therapy.  It’s not up to the therapist to create motivation to stop drinking. Living in the world as a serious problem drinker eventually creates enough motivation (for some; not everyone) to give therapy a chance (usually with a strong push from an important other). Once therapy begins the work is to address the pain, loneliness, etc. that drives and maintains reliance of alcohol to make life bearable (same point applies to addictions).

I cannot overemphasize how unrealistic it is for anyone (client or involved others) to expect a quick fix. The fact that the client has needed to rely on alcohol to make living life bearable is a signal flare—it signals deep seated distress, mistrust of others and associated longing for self-sufficiency, loneliness, alienation, etc. It also signals a harmful background in one way or another involving the most important people in the client’s life (currently if the client is young,; at least historically if the client is older, although it is common to observe that the old harmful relationships continue to exist in the present in a form that is little different than the distant past). There is an understandable wish on the part of the client and involved others to think of a drinking problem, even a long term, serious drinking problem, as a simple and circumscribed behavior that is amenable to rapid fix by expert treatment personnel. Unfortunately this is an illusion (or a delusion if the client or involved others cling to it over time). A well established, serious drinking problem is the tip of a psychological iceberg.

A word on AA or other support/recovery groups. Since serious problem drinking indicates a turning away from involvement, trust, etc. in people, one way or another the client must evolve from trusting alcohol to trust and involvement with people if alcohol is ever going to drop from the number one option for coping with the pain of living. In this sense all dedicated recovery groups where one can find support, understanding, encouragement, acceptance, fellowship, etc. is clearly a good thing. A recovery group is not a spouse or an employer; in other words a recovery group is not a person or organization that looks to the client to fulfill important needs. This allows exceptional tolerance and acceptance, to say nothing of the empathy and insight that fellow travelers can provide.

At the same time, recovery groups should not be expected to function as therapists. Of course there is overlap between a good friend in recovery and/or a sponsor and a therapist, but I don’t think it’s fair or realistic to think a good friend or sponsor in recovery can substitute for a therapist. How to say why succinctly? It takes a lot of training and practice and supervision to become a therapist. Part of the training and practice and supervision is dedicated to unlearning the natural responses and thoughts about being helpful one acquires in everyday life. Therapy is not a form of cajoling, argument, or advice giving, three responses high on the list of strategies for being helpful one acquires in everyday life. Actually as I conceive of it therapy is paradoxical: important change derives from consistent acceptance, empathy, astute listening and understanding, accurate identification and naming of fears, conflicts, and so on. Paradoxical because the therapist is not pushing for change, yet over time change occurs because the therapeutic relationship inspires more trust and involvement and less fear and withdrawal. This is what actually changes how a person thinks and feels about himself and others over time, and as such change occurs turning away from people and relying instead on alcohol (or some other addiction) to find life bearable becomes a less favored option. The person no longer above all else wants to use alcohol to go away.

Inwardness, Marital Discord, and Porn

A positive, nurturing, etc. upbringing psychologically prepares a person to successfully meet the challenges that inevitably arise in an intimate relationship. I say inevitable because there will always be some friction at times between two people, no matter how well suited they are for each other. The other person in a relationship is another person, with his/her own needs, values, perspective, trigger points, moods, idiosyncrasies, foibles, quirks, blind spots, and so on. No one’s needs, wants, etc. are fulfilled 100% of the time by one’s partner or spouse. Thus all relationships are challenging in certain ways and degree. Read more

Does Couples Counseling Help Relationships?

Does a marital crisis or some very disruptive marital event (e.g., wife discovers husband watches porn) indicate that marriage counseling is indicated? I am often asked this. For many people it seems natural to suppose that a significant and threatening marital conflict indicates marital counseling, but I think the matter requires some thinking through.  Read more

Most Psychotherapy Is Long Hard Work

Perhaps psychotherapy is misleadingly named. What does ‘therapy’ bring to mind? Everyone understands that psychotherapy means treatment. Everyone is familiar with medical treatment and dental treatment. The role of the patient in medical and dental treatment is to bring your body to the treatment site and endure what they do to you. Or take your medication as directed. Either way, you contribute little as an active participant. The success of treatment does not depend on you actively participating. By ‘you’ I mean you the person, not you the body that is being treated. A few years ago I had a hernia operation. Some kind of mesh was used. I have only the vaguest idea what was done. Nevertheless, the operation was a success.

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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.
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Facing What Happened | What Lies Beneath Addiction

Karen Horney, a pioneering revisionist of psychoanalytic theory in the 1930s and 1940s, once remarked that in the main what people in analysis wanted was not cure but rather not to be so inconvenienced by their neurosis. In plainer language, and to address this to addiction, what most people want is to ‘eat their cake and have it too,’ to be able to use but for the use to not get so out of hand and produce so much trouble in living day to day. To basically do the same thing and be the same way but a little less.
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Is Porn Bad For You?

Is Porn Bad For You? I’m talking about the videos you watch on the internet. I’m not interested here in examining what distinguishes artistic rendering or examination of human sexuality from porn or in examining if porn is simply a term of disapproval on the part of someone for something that another person does not find objectionable. Again, I’m talking about what you watch online that is commonly understood as porn.

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How Does Change Occur in Psychotherapy?

I think it will be helpful to me and to prospective and beginning clients to try to provide an overview of how I think about …

Make-Believe in the Addiction Treatment Industry

Therapists shouldn’t be in the business of make-believe. There is a great deal of make-believe in the addiction treatment …

Magical Thinking About Drinking

Most of the people I see who have serious drinking problems express the hope that they can over time acquire the ability …