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Articles by David H Jacobs Ph.D

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. If you can bring yourself to trust and confide in the therapist then you can talk about the pain and distrust (of people!) that makes turning to and relying on alcohol or some other drug so enduringly appealing despite drawbacks and consequences. Confiding and trusting without disaster and with repair of misunderstandings and disappointments is a novel relationship and a novel experience. If you can establish such a relationship over time with a therapist then you become different, which is the point.

What is make-believe on the part of many programs and approaches in the industry is the attempt to treat alcohol or drug reliance as a bad habit that can be coached away (or coaxed away). That’s make-believe because alcohol or drug reliance is not a bad habit’”it’s an attempt to obtain relief from one’s inner malaise without turning to and thus being vulnerable to any person. Trying to slide around this is something like trying to treat malnutrition by supplying everything but food. A malnourished person may need medical care regarding the consequences of malnutrition (medical conditions brought about by malnutrition), but medical treatment for such conditions cannot replace the primary need, which is for food. Similarly, a person who relies on alcohol or drugs to render life bearable due to inner malaise and interpersonal distrust primarily needs to address and ameliorate that, although beneficial treatment may also include elements of instruction or education (for example, being helped to see that cravings fluctuate in intensity over the course of a few hours, or being helped to recognize how one rationalizes beginning to drink). But focusing on adjunctive/ancillary considerations is useless in the long run (which is of course the point) if the actual problem is ignored. The actual problem, as I have suggested, is ongoing inner malaise coupled with the conviction that reliable relief that does not entail excruciating psychic vulnerability can only be obtained by a psychoactive substance.

Programs or therapeutic approaches that do not primarily address emotional malaise and interpersonal distrust in effect appeal to the client’s understandable desire to avoid the painful psychological realities driving alcohol or drug reliance. It is one thing for the client to endeavor to avoid coming to grips with the painful psychological realities that motivate and sustain alcohol or drug reliance. This is par for the course because pain motivates avoidance if at all possible. It is something else entirely if the professional(s) purporting to treat evade the most pertinent psychological realities. This is bad faith. Bad faith is a term from existential philosophy. I draw upon it here to refer to adoption of an approach to treatment that in effect conspires with the client’s desire to avoid painful but critical realities. It’s bad faith on the part of professionals because it amounts to a betrayal of the client’s trust that the professional will say and do what is genuinely in the client’s best interest. It is not in the client’s best interest to evade the issues that actually drive and maintain alcohol or other drug reliance. Evasion will occur if the structure of treatment does not provide an opportunity to establish a relationship with a therapist that deepens over time and is dedicated to surfacing the client’s pain and mistrust. Everything else has a transient effect at best.

It’s pointless to hope that temporary enclosure (‘rehab’) will have an enduring effect. If a person is removed from his habitat and lives for a short period in a protected therapeutic environment in which there is no access to drugs and he is monitored around the clock, a period of abstinence will ensue that precisely coincides with his tenure in the residential facility (this is ideal; in practice there may be drugs circulating within the residential facility). The hope that what occurs during his stay in the residential facility will bring about an enduring shift is idle because what really matters and makes a difference to a person with a serious alcohol or drug reliance problem cannot develop rapidly. What is needed is an ongoing relationship of trust with a benign other that over time modifies the feeling of aloneness and inner malaise that makes turning to a substance so enduringly appealing. Only a new and different human connection can come to compete with the reliability and safety of turning to an impersonal source of relief’”a source of relief that is completely predictable, under personal control, never fails, never says no, never disappoints, etc.

Reliance on alcohol or a drug to render life bearable is misconceived as a problem in its own right. It’s more realistically viewed as a marker, an indicator, a sign’¦The real issue come more readily into view when alcohol or drug reliance is seen as part of a bigger picture of turning towards what is impersonal and away from people, away from reliance on people, from relationships, from trusting people, from intimacy’¦There must be something quite amiss psychologically for a person to make a substance his closest friend, ally, lover, significant other’¦True, as adults many people that rely on alcohol or drugs are married, but this only highlights their investment in and need to seek refuge and relief via use of a substance rather than via emotional closeness, connection, intimacy, and so on. It’s crucial to see reliance on a substance as turning away from emotional vulnerability and connection rather than as simply turning toward and preferring altering mood and feeling state via drug use. It’s a simple point I think once stated but the point is very frequently overlooked: alcohol or drug reliance is not just alcohol or drug reliance, it is simultaneously turning away from people and relationships as a way of anchoring oneself in life and obtaining security, comfort, support, and so on. Both features, but especially the turning away from closeness, connection, and intimacy with people, point to an injury not just to the ability to self-soothe/comfort by drawing upon inner resources, but also with regard to trusting, getting close to, and connecting with people.

The psychological injury is hard to bear. It creates more or less continuous inner malaise that needs to be soothed. If the therapy environment is receptive and encouraging of client self-expression, the client will speak of variations on malaise/inner distress’”anxiety, agitation, ‘boredom’’¦Practically all clients refer to boredom as a preamble to alcohol or drug use. Boredom, as used by people who rely on alcohol or drugs to make life bearable, is really a code word for distressing agitation and restlessness. It’s what comes strongly to the fore when the person is not absorbed in some activity. It’s hard to endure and hard to get rid of. It makes alcohol or drug use attractive. It’s lurking in the background all the time. It’s the psychic/emotional legacy of growing up in a noxious family environment. People who grew up in families that supplied security, emotional responsiveness, benign attention, thoughtfulness about the needs of a growing child, comfort, caring, love, and so on do not develop a chronic background feeling of malaise and restless agitation, in addition to a fundamental distrust of others, such that relying on drinking or drug use is the only path actually open to them’”because self-calming/soothing inner resources are meager and because there is too much basic mistrust regarding other people to actually feel that it is safe to turn to another person in time of need in an unguarded manner.

The above formulation makes comprehensible why alcohol and drug reliance is so hard to treat. Treatment that does not really touch the person’s inner malaise/distress and mistrust of others is ineffectual in the longer run (the only thing that is important); the only experience that can alter chronic malaise and basic mistrust is coming to deeply connect with and trust a therapist over time’”precisely what people who rely on alcohol or drug use are strongly disinclined to do. I say a therapist because only a therapist is in the position of becoming involved deeply enough and long enough without the fulfillment or hope of fulfillment of the kind of personal needs upon which marriage or some other powerfully committed alliance depends. It sounds like a paradox and to some extent it is’”the person who relies on alcohol or drug use to make life endurable must actually stick her neck out with a therapist and risk the kind of vulnerability she fears risking. The unadorned truth is that many addicts leave therapy as soon as they can’”as soon as whoever is pushing or threatening or ultimatuming cools down sufficiently. They return to the devil they know. Therapy is a relationship, a two way street. The therapist has to be realistically prepared to face the difficulties that go along with doing therapy with an alcohol or drug reliant person, but ultimately one cannot dance with a partner who does not want to dance and is not trying to dance and just wants to get off the dance floor asap. What the therapist can do is endeavor to make the being-together as safe and reassuring as possible so that trust can develop over time. The therapist can draw upon his experience, sensitivity, acumen, etc., but the therapist can only do his part, he can’t do both parts. Good things can happen over time if the client sticks around. Basically the therapist must try to appeal to the client’s severely burned but not quite dead wish to be understood, connect, and trust. If there is also a feeling that living the same way is just not viable, then maybe lift-off. If not now, then at a later time (people do return at a later time when there is more of a feeling that going on in the same way just can’t continue).

In summary, the most visible and popular forms of treatment for alcohol or drug reliance engage in make-believe about what the real problem is and what will actually have potential to beneficially address the real problem. Naturally a lot of money changes hands.  Beautiful settings and five star food do not alter the picture. There is no quick and enduring fix because the pain and mistrust that makes drinking or other drug reliance the best psychic-emotional choice despite consequences cannot be altered quickly. A therapy relationship with a specific person is not transportable. Once it’s over it’s over and the client must begin anew. Therapists are not interchangeable units. What makes practical sense is to seek a therapist to work with for the long haul because it’s only the experience of developing deep trust and connection with a specific therapist that will actually make a difference. The rest is basically window dressing.

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