Addiction, co-occurring conditions, and Humanity 101

If you’re a regular on this blog, you probably know that Peter Sheath and Matt Robert have enough knowledge, compassion, and common sense about addiction and recovery to lead us to a far far better world. I’ve grabbed these gems from their comments to a recent post. If you’ve already read them in context, well read them again. If not, now’s your chance.

Peter Sheath:

PeterSheathI feel like there is an amazing amount of synchronicity going down, especially between you [Marc], Matt and li’l ol’ me. I can almost guarantee that I will have had my interests stimulated by a client, book, lecture or simply talking to someone and, a few days later it will be there in your blog and Matt will have made one of his beautifully eloquent comments on it. This may not sound so apparent at first but please bear with me.

Over the past couple of years I’ve been doing a lot of thinking, talking and research around this whole co-occurring conditions/dual diagnoses thing. I think we, organisationally, have got astonishingly good at not dealing with it. We love to have these imaginary silos that we place people into, develop manuals and protocols to either keep them there or embargo them from going there. We’ve even developed competency/accountability frameworks, skill-sets and governance systems that ensure that, supposedly, the right person is working with the right person, at the right time, in the right place.

The trouble is that it mainly creates confusion, uncertainty, apartheid and exclusivity. Only the other day I received a phone call from a friend who is managing a substance misuse team for people with complex needs. He had been asked to develop a “criteria” for the people his team would be working with. I said that I’m very sorry but I really do not believe in having criteria for people we do or don’t work with and everybody who comes to substance misuse services for help will have complex needs. Turns out that he is of exactly the same mind but has to do it because that’s what he’s been instructed to do.

Doing things in this way means that we often screen more people out than we do in and I have real difficulties understanding why we continue to do it. Jordan Peterson’s 12 rules for life, motivational interviewing, open dialogue, ACT, CBT, person-centred counselling, narrative exposure, etc. are all transdiagnostic and probably work best under the collective umbrella of the therapeutic relationship.

I’m currently working with a paying client who has had a lifetime of psychiatric diagnoses and various dependencies. He came to me because he had approached his local alcohol service looking for a community alcohol detox. The detox would need to fit around his work, because he works for himself and is the only employee. He was drinking at least a 750-ml bottle of vodka every day and was getting increasingly desperate and depressed. The service said that, because of his underlying mental health problems, levels of alcohol use and not being able to take time off work they couldn’t help him! I know it beggars belief, doesn’t it? I negotiated a course of Librium with his GP, involved his mother and his local pharmacist in the plan (open dialogue), then did some motivational interviewing type interventions to boost his confidence and ensure that getting sober was the right thing to do. We arranged a daily telephone check-in and weekly face to face, with myself, and I taught his mum and him how to do blood pressure monitoring. He agreed to call in to the pharmacy if his BP raised or reduced by 10.

Got a phone call last night to say that his detox had finished a week ago and he is now 21 days sober. He has struggled a bit because the weather over here has been lovely and he has an association with sunny days and sitting outside the pub drinking beer. He has used some psychotropic meds sparingly, because he does get worried about his anxiety levels, panic attacks and past psychoses. I’ve also been teaching him mindfulness-based meditations, relapse prevention and managing his mental health. We’ve developed a really good therapeutic relationship based on trust, autonomy, prosocial role modelling and hope. We’ve also focused on very small steps, although he is always wanting to make massive leaps. Fingers crossed.


Matt Robert:

photo-2-1Hey Peter!! It keeps coming back to this, doesn’t it? It takes a village…but a coordinated one that meets the needs of the individual as well as the tribe. Your sentence captures it all:

“We’ve developed a really good therapeutic relationship based on trust, autonomy, prosocial role modelling and hope.”

There has to be autonomy, agency… individuals need to feel in control or we don’t feel safe. I have to trust my fellow participants, the method, the goal, because I’m not going to stick with a process of arduous change if I don’t believe in it. And none of it is gonna work if I don’t feel like I’m in a sharing, connected, reciprocal relationship with the humans who are helping me. Something all effective recovery traditions have in common. All human endeavor, for that matter.

The thing about open dialogue that is so simple and compelling is that it is the same model humans have used to cooperate, help each other, and progress throughout history. It’s getting all the stakeholders, the people who care, in the same room, on the same page. It’s putting the puzzle that’s fallen apart back together.

We all know how to do this because it is a human thing, not an “addiction” thing. Addiction is a proxy for meaningful relationship.

11 thoughts on “Addiction, co-occurring conditions, and Humanity 101

  1. Terry June 20, 2018 at 11:08 pm #

    In so many ways the worst thing for people dealing with addiction is those who purport to be helping them – because the systems create so many hoops to jump through and then if jumped through a person is told what to do and labelled for life and what they want is ignored and if they do not succeed or are not willing to do what they are told they are flung out and labelled as being in denial. There are some people who change despite what the treatment does to them, there are others who give up and die. There is nothing different about drug users to anybody else in so many ways except what they choose to do in order to feel a little pleasure, a little peace. The trouble is there are too many to help and too few who can give the intense help needed. You are right Mathew – its not addiction that’s the problem its the relationship the individual has with themselves and thence others, a relationship soured in infancy and added to with stress and trauma that results in people hating themselves. Love is the answer and the therapeutic relationship is often the first time many have felt that someone cares.

    • matt June 21, 2018 at 4:35 pm #

      Thanks Terry. So true and eloquently put.

      There are many recovery gatherings and treatment modalities based around these unsound methods. What human likes being told what to do? What human likes to be judged disparagingly? The labeling and castigation need to stop, and the shared experience of being heard needs to be deepened. Not worrying about what people are doing but why and how they are doing it. My difficulty in asking for help was made worse not only by the shame I felt from societal preconceptions, but also from the feeling that I didn’t deserve it. I didn’t deserve any better.

      We all deserve a better life. And the right therapeutic relationship can be the door that opens into the light.

  2. Gary June 22, 2018 at 9:58 am #

    We definitely live in a world of labels, which in many respects, tends to help the “clinical person” cope with their own urgency of order, structure and/or box. How is it ever possible to be genuinely present with another once we have attached a label? What kind of treatment is it if a clinician comes with there own preconditioning and expectations of how a client or patient ought to respond and if the client and/or patient fails to fulfill the preconceived outcome are labeled “noncompliant” or “not motivated” etc. Many of us have forgotten how the art of listening, altruistic compassion and unconditional positive regard for another human-being as essential scaffolding in terms of the therapeutic relationship. In other words, having to good ears and compassionate heart. My own personal experience and journey into a world of addiction was, in my own opinion, salvific and not quite sure what the alternative might have been, at the time. However, I eventually hit my own “rock-bottom” though the core of me felt “bottom” to be “bottomless”. It was as though I had no choice but to look directly into my soul facing the shame that brought about it’s own clarity. As an addict I had to look deeply, without judgment, in order to see what was. It only makes sense that clinicians ought to do the same in order to appreciate another human being in pain.!~ As long as we observe with our own preconceived images then it is most difficult to understand that the observer and the observed are one, this! is in and of itself is the highest form of intelligence and numinous Love!~

  3. matt June 23, 2018 at 6:20 am #

    Thanks, Gary!

    This is so important. I especially align with your beautiful comment:

    “Many of us have forgotten how the art of listening, altruistic compassion and unconditional positive regard for another human-being as essential scaffolding in terms of the therapeutic relationship. In other words, having to good ears and compassionate heart.”

    This might be a volatile question. Following one of the foundational principles of 12-Step, addicts helping other addicts, do you feel that clinician’s who “treat” people with harmful addictive behaviors should themselves have relevant “lived experience” with addiction to be most effective? How do we help people extract the toxic narrative to neutralize labels? How do we measure compassion, empathy and altruistic intention?

  4. Dr Ron June 26, 2018 at 1:55 pm #

    Having attended numerous 12 step meetings over the years,and understanding the power of labeling, I quickly soured on tritely proclaiming myself an addict and just introduced myself merely by name when sharing (which incidentally drew all manners of enmity). Henceforth, I’ve been inspired to introduce myself with a “Hello..I’m Ron..I’m human”.

    I find the nuance profound and aspirational as I am much less intent on minimizing my worst “Addict” self than maximizing my best “Human” self and all finest traits aforementioned that humanity entails. Words matter…just a thought.

    • Neil July 1, 2018 at 11:52 am #

      Great post Ron. One of the drawbacks of the 12 Step model for me is the ‘once an addict, always an addict’ mentality. Now, will I always be vulnerable to cognitive distortions and the siren’s song of my drug of choice … maybe? Probably? But to still label myself as an addict seems very limiting to say the least.

      I did once say to a counsellor that while I love the fellowship of my group having to say my name is Neil and I am an addict every single meeting feels like it discounts all the hard work I have done to move through my addiction – I don’t consider my self an addict, nor a recovering addict I am a human moving through my addiction to a healthier place. Do I still struggle with unhealthy and unproductive thoughts and compulsive behaviors? Sure. That makes me human.

      Alternative for me were my name is Neil and I struggle with compulsive XXXX or some variant. A counsellor asked my I didn’t say that and for the same reasons you said – there would be uproar from the group? Oh he’s in denial, his addict is talking.

      Although same counsellor reminded me a few weeks back when I told her something I had been ruminating on that ‘as an addict my best thinking got me here” Way to go! Rather than examining potential cognitive distortions, which could be possible, it was a ‘down boy, don’t get too big for your boots”

      • Fred July 1, 2018 at 1:55 pm #

        I think of the “I’m Fred and I’m a _____ addict” ritual as a password of sorts – it’s a way of saying, “I want to be here, I belong here, I too struggle with this substance/process, we’re in this together and I value this 12-step solution.” By using the language customary to the group, I’m honoring the group. Similarly, I can take my shoes off, or cover my head, when I enter a particular holy shrine without it meaning that I adhere to every single belief of that particular religion. The words of introduction can be more about honoring and respecting the forum than “labeling” oneself. As an aside, in the groups I attend, I hear all kinds of variations – “I’m a grateful recovering _____”, “I’m a person in recovery”, “I’m grateful for one more day”, etc. In 12 years in the rooms, I’ve never experienced anyone getting negative feedback for how they introduce themselves (though I’m not denying it might happen in other meetings – maybe I just attend some easy going groups!).

        • Neil July 1, 2018 at 3:51 pm #

          Great points Fred!

          • matt July 3, 2018 at 5:19 am #

            Great points, all!

            An underlying theme which makes perfect human sense: nobody likes to be told what to do or judged to be inferior… especially for the way I envision or conceptualize my re-entry into my own life. And even more so if it’s working!! Creating cognitive dissonance for vulnerable people in early recovery is never helpful.

            That said, I always respect the cultural norms of any organized group I choose to enter. If I find said norms to be personally untenable, I can leave. The difficulty arises when there are no options for such a vastly differentiated phenomenon of the human condition.

  5. Carlton July 11, 2018 at 6:38 am #

    Here is an interesting article today from The New York Times:

    A Restaurant Takes On the Opioid Crisis, One Worker at a Time

    A Kentucky couple realized that restaurants have an unusual power to help addicted people recover, and created DV8 Kitchen to hire, train and encourage them.

    This sentence popped out:

    Working the grill, she said, “is a huge coping skill for me.” Making burgers, “adding the spices, the egg on top, making the homemade Dijonnaise,” and then seeing customers’ reaction when they take a bite, brings “a sense of accomplishment,” she said.

  6. Mark July 13, 2018 at 9:27 am #

    When I truly realize just how vulnerable we all are to our genes and our neurobiology, I can’t help but have compassion for myself and other people …

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