I was talking to a friend the other day. We were having a socially distanced chat at our local park , updating each other on everything life and sharing what’s new on the therapy front. I always enjoy my chats with this fellow colleague who has the capacity to enrich my world view and understanding. From that conversation, I felt finally ready to put black on white some of the thoughts I have about my work and more generally about mental health.
I would like to start with a series of considerations on what I have noticed about the language we use and the attitudes we have when working with people who use substances. More broadly, this post is about showing that as practitioners (and human beings) we can have a kinder and more radical impact on someone’s life when we listen rather than judge.
‘Addiction’: a controversial word
We cannot talk about ‘addiction’ without considering first what this word really entails. I won’t indulge here in an exploration of its semantics, nor will I produce an essay on it’s biomedical-related implications. I want to dwell a bit on what the word ‘Addiction’ does as a label. As a person-centred therapist and above all a human being, I cautiously use labelling terms to describe any of my clients’ behaviours (or anyone’s behaviours, for that matter). I would rather say, by making a political statement, that I simply don’t use them. After all, my work as a therapist is political and I wouldn’t consider my work either trauma-informed or feminist if I didn’t reject terms that would further oppress and pathologise my clients. ‘Addiction’ is one of those words, and that is why I put it in brackets: it needs contained so it doesn’t cause further harm.
I am aware though that we live in a society where such word is used to ascribe and prescribe and, like any other label/diagnosis, this term opens doors to treatments that for some may feel like a life-saving offer of help. Labels/diagnosis may feel helpful to put some thoughts in order, to find a beginning of a too complex jigsaw, a support to assemble those borders first. But once that label is there, it is all that there is. The person disappears behind a list of symptoms and medication. The reasons why certain behaviours are there are mainly explained rather than understood. And the more we focus on the ‘addiction’, the further we move away from the person we have in front of us. At what pro?
The label ‘addiction’ doesn’t take into consideration someone’s personal history of trauma(s), the environment, nor the isolation and sense of alienation that come along with using coping strategies in ways that are frowned upon by society. I won’t purposely make a distinction between the different coping strategies here, whether it is food or sex or substance to name a few, because they are all frowned upon, just in different ways (think about what diet culture says about the use/restriction/deprivation of food, for example). But I will purposely state that the use of the word ‘addiction’ is rarely a solution.
Behind the ‘addiction’
In a decade of working with people labeled with ‘addiction’, I noticed a correlation between the word ‘addiction’ and mental health struggles, but little emphasis was rarely put on the latter. When I started volunteering then working for a counselling service for those affected by theirs or somebody else’s substance use, it changed completely the way I was looking at this phenomenon.
I learnt to put the person first.
I learnt that the relationship between the person and the substance is what
creates pain in the present.
I learnt that there is no difference in aim when choosing a coping strategy,
the difference lies in the legality and availability of it.
One of my favourite frameworks to work with a person who has a problematic relationship with their coping strategy is the “Window of Tolerance”. The term, coined by Dr. Dan Siegel, is used to explain people’s reactions to adversities in relation to their optimal arousal level. Outside of that window, the person would feel overwhelmed and would engage with different strategies to bring themselves into optimal levels again.
A way to understand this is by thinking about a time when you felt flustered but not overwhelmed. What you did next was to access some sort of coping strategies to bring yourself back to a place of balance, maybe a couple of deep breath, a warm cup of tea or a walk in the neighbourhood or a chat with a friend. You may choose it or it was something you did without thinking, almost automatically.
Now, think of a time when that didn’t feel possible. Nervousness starts kicking in and you become overwhelmed by the situation. You may feel out of control and frightened. What would you do? You would look for comfort, something that would sooth you quickly, and possibly didn’t take up a lot of energy either in a quest to regulate yourself. In that moment, you go for what is working.
Stressors and triggers are easily dealt with when we respond from within our windows of tolerance, but complications arise when we lose control of what is happening.
Meditation, fresh air, yoga and a balanced lifestyle although ideal are the answers for some people but may not be the answer for others. Privilege shapes the level of accessibility to certain coping strategies over others whereas oppression removes the hope we could ever access those coping strategies (or even think about them). Even without these aggravating factors, coping is essential to emotional regulation which then allows us to feel safe enough. Whatever the activity, our actions fall within this, the need to feel safe again when triggers of various forms and nature tell us that there’s danger and our life is at risk.
A person-centred way
Working with ‘addiction’ presents its own challenges. On one side, it requires energy to navigate stereotypes and prejudices in order to listen to the person’s pain. On the other side, internalised stigma belongs to clients as well. In a system that focuses on the ‘addictive behaviour’ rather than the person, it is difficult to not get stuck in profiling the person’s behaviour around said substance and continue on a narrative that fundamentally excludes the person from a picture you are together creating of them. It also becomes difficult to not lean towards and take advantage of the ‘I tell you everything about my addiction’, which is a behaviour requested by the system in exchange of help.
Exploring the inner landscape can take many forms. It’s like assembling a jigsaw.
At the beginning, it’s about finding out how the person likes to approach the puzzle making, if they like to start from the centre, if they like to focus to one section at a time, if they prefer following a method or whether they have ever worked on a jigsaw before.
The only way to gather all of these information is by actively listening whilst putting aside all that noise that would otherwise blur our ability to be and stay open. It also requires us to put aside our own ideas of what is right from wrong and what we think it’s best for the other person. No matter the reasons that convince us that we know best, especially so because we read it on a scientific paper or we heard it from an ‘expert’ in the field, people are unique individuals, not textbooks, and trying and fitting them into a pre-made schema is just as oppressive as that stigmatising vocabulary we are all trying to stay away from.
One of the first questions I like asking my clients is: what would you like to achieve with therapy? So simple, yet so efficient. That question alone can already invite us into the client’s world. It shows us what the client’s expectations are and somehow it draws the boundaries of what therapy is there for for the client. Mind, those boundaries are not definite, they are fluid and they may change during therapy. But it’s important to respect those boundaries and put my personal agenda aside so trust can be built upon it.
Then, there are frameworks that I use to understand the experience of the other person, such as the ‘Window of tolerance’. Sometimes I share the framework I am using, other times the occasion may never come. I always use my curiosity to understand better, to support the person to explore behaviours and patterns and thoughts and feelings. It is in the process of discovering oneself that the relationship with the problematic coping strategy changes. The way it happens, the timescale, the clarity in which happens is unique to the person. For some, it will come in the form of epiphany, for others it will be gentle and quiet.
And you, how will you talk about this?