When confronting issues of substance use, professional opinions as to what constitutes use, abuse, or dependency, as well as notions of prevention, often compete with the ideas of individuals and families, and those of the culture at large. Recently, a client who proclaimed himself an addict looking to abstain from drugs, asserted: � I wanna� quit drugs, I just wanna� drink from now on.� The misconception that drugs exclude alcohol is an example of a distorted but all too pervasive belief. Similarly, clients often believe that the consequences of drug use are confined to the period of intoxication, and do not extend beyond that time. As therapists working with such clients, we must confront these distorted belief systems before we can clarify treatment goals. In this article, I will discuss some important ideas pertaining to substance use, and present interventions that are substantive and practical.

Distorted Beliefs about Addiction

Inverted notions about risk-taking: Our beliefs can help us or they can mislead us. Negative beliefs about self, for example, can form the psychological fuel of an escalating substance dependency. Conversely, a positive self-image can inspire self-care. But in the inverted universe of substance abuse, definitions/ideas of positive self-image and positive self-care are turned upside down. For example, when speaking to adolescents, I often comment that an emotional and behavioral change that occurs relatively early in drug use is that of increased risk-taking and impulsivity. Drugs are dangerous, I add, not to mention illegal and largely forbidden. There is generally a respectful agreement on this point, but I also note when my clients seem unmoved. After all, I can see them thinking, risk-taking is manly, risk-taking is good. The willingness to take risks garners esteem within a peer group and creates a false sense of heroism within the young person. This twist of thinking has significant implications; under social pressure, what we commonly think of as self-destructive risk-taking is perceived by our adolescent clients as courageous. How can we �coopt� the positive value attached to risk-taking and turn it right side up again? I believe that the key lies in redefining risk in emotional terms: It takes courage to risk being honest with others, to stand strong in the face of peer pressure and dare to accept limitations, protect our safety, and adhere to conventional behavior.

Negative reinforcement for intoxication: Drugs are intoxicating because they promise an instant way to alter our feelings. Seconds, minutes, perhaps an hour, is all that is necessary to achieve a desired effect, and the message to our central nervous systems is clear: you do not have to wait to change how you feel. When asked what is attractive about the mood and mindaltering experience, addicts will first give some familiar responses: drugs allow for disinhibition, increase confidence or relaxation, and create a feeling of elation where there was anxiety before. But deeper exploration reveals more: As feelings change, so, too, do the user�s perceptions: responses to stressors are intensified, confidence turns into entitlement, and the user, filled with false confidence, misreads social cues and perceives social approval where there is none.

Withdrawal brings with it even more distorted thinking. The absence of the intoxicating high feels punishing to the suffering addict. But what is he being punished for? For using? Or for not using? For the absence of the drug in his system, or for its presence? After all, the best way to eliminate the suffering of withdrawal is with further intoxication. The addict comes to the wrong conclusion: he believes he is being punished for not using, not for using. Onlookers may reinforce these conclusions by reacting more aversively to the negative effects of withdrawal than to the negative effects of intoxication. Consider the logic of what I might term the �they like me better when I�m high� effect: When intoxicated, a user may be relaxed, more confident, and more sociable. When not intoxicated, they may be irritable, complaining, anxious, and lethargic. Whom do we want to be around?

The �think before you act� fallacy: Science has come to understand that drug use inhibits maturity, and that addiction has more to do with biology than with character. According to a recent article in the Harvard Mental Health Newsletter: �human brain circuitry is not mature until the early 20s. Among the last connections to be fully established are the links between the prefrontal cortex, seat of judgement and problem solving, and the emotional centers in the limbic system. These links are critical for emotional learning and high level self-regulation.� The implications of this research are that youth is particularly vulnerable to addiction. Though we may want them to �think before they act,� research teaches us that the integration of thinking and feeling, that ability to distinguish between what we think is important (i.e. a craving state), and what is really important, is a matter of development and time. Teenage brains are simply not yet developed enough to make these distinctions. Drug use then further inhibits this development, because it undercuts one of the cornerstone tasks of maturation, namely, the practice of patience and the tolerance of discomfort.

Social norms are complicit with drug use. Advertising associates alcohol and tobacco use with sex, popularity and fun, and creates an environment in which immediate gratification is a commodity. Society reinforces the �life lessons� of addiction: the belief that impulsivity, intense experiences, and quick relief from bad feelings are the important goals and not dealing with, and learning from, the ups and downs of life. The sober experience of life is implicitly devalued, and not using, not being high or intense, is defined as �square.�

The myth of responsible drinking: �Drink responsibly,� the ads and commercials warn us. Although many can and will obey the limits, many others will struggle, fail, and suffer the consequences � legal, occupational, relational � that accompany abuse. Still others cannot even engage in the struggle. Mainstream society either misunderstands, or plainly rejects, those for whom the very term �drink responsibly� is a contradiction. We are still a long way from grasping the notion now understood by the medical establishment, and best articulated by the twelve-step community: that for those who self-identify as addicts, addiction (or dependency) is a state of being, and not a matter of choice.

The Emotional Work of Recovery

As a result of this thinking, as well as other misconceptions, what is communicated to the struggling user is often inappropriate, if not counterproductive: misguided attempts to control use or narrow goals centered around the tangible effects (legal, medical, or occupational) of drug use. �Getting my life under control by getting my drinking under control� is a potentially dangerous fallacy. What is missing is an attention to emotional changes that distort thinking, and ultimately change relationships. Terry Gorski (in Passages Through Recovery, 1989) describes a �post acute withdrawal� phase, a time of emotional and behavioral changes that lingers twelve to eighteen months into a period of abstinence. Recovery programs refer to analogous concepts � �dry drunk� periods, or �white knuckling.� Long after the last drink has been taken, recovering addicts may have problems thinking clearly, be prone to irritability and conflict, sleep restlessly, feel vulnerable and even believe that they are going crazy.

Many addicts state that a primary goal in therapy is to regain the trust of their loved ones � parents and spouses who have become indignant towards their lying, secrecy, and manipulation. But they often become frustrated because they fail to recognize that the task of regaining trust is a reciprocal one. The mental and spiritual aspects of the disease create a negative relational cycle. The user lies, the loved one colludes with the lie. The user pretends they are clean or blames their drug use on others; the loved one agrees to believe them. The addict says �let me handle it� or �I�ve got it under control� as a way of avoiding scrutiny; the loved ones back off. They subscribe to the myth that the addict can and will control their use. This denial of reality leads users back into the cycle of use, and loved ones into despair. Provocative questions to addict clients often include: �Do you trust them enough to tell them the truth?�; �Do you trust them enough to allow for their questions?�� and especially for youth � �Do you trust them (your parents) enough to accept their limit-setting, to allow them to parent, and to allow yourself to be a kid?� The purpose is to reframe the task of regaining trust for users and their families, because the greater challenge is not that of users gaining the trust of would-be helpers, but, rather, that of helpers gaining the trust of users.

The following is a summary of important messages for substance users and families:
1) Mental and behavioral effects of drug use are not confined to an intoxication syndrome.
2) Risk-taking needs to be redefined in emotional terms; the courage to be honest and accept limitations replacing the false bravery of self-destructive behavior.
3) The �they like me better when I�m high� effect: When we confuse the negative effects of intoxication with those of withdrawal, we unwittingly reinforce drug use.
4) The development of maturity is arrested by regular drug use. This statement is not a value judgement about a person�s selfhood but, rather, a truth about biological development.
5) The mental and emotional fallout of addiction continues long after usage stops.
6) The trust wound between substance users and their families is a mutual one.

Intervening in the Addictive Cycle

Some time ago I worked with a father and son who were struggling to communicate regarding the son�s substance use. The son, Eddie, 18, had been living with his father, Mike, for two years, following his parents� divorce six years earlier. Eddie had begun using drugs (notably alcohol and marijuana) at age 14, and exhibiting defiant behaviors at home and at school. After Eddie completed a ten-week outpatient treatment intervention, father and son were referred to me for therapy.

Eddie presented as motivated to change his behavior, but was consumed with anger about his father�s distrust of him. �He never believes anything I say�, he�d complain, to which the father would retort, �You don�t give me reason to.� Both Mike and Eddie agreed that they wanted to regain mutual trust, but they were locked in a cycle of mutual blame. Mike occasionally pretended to trust his son in order to de-escalate conflict, but ended up disillusioned whenever Eddie relapsed. Eddie ended up guilt-ridden. I asked the father and the son to each take responsibility for their own thinking, feeling, and solutions and to set a realistic foundation for the rebuilding of trust.

Eddie and I focused on identifying his problematic thinking, and redefining his ideas about risk-taking. He was aware of the risks associated with drug use: Eddie had been both arrested and suspended from school for intoxication- related offenses. When asked about the risks associated with sobriety, and the acceptance of his father�s house rules, he struggled with feelings of resentment and was unable to imagine how his life might change for the better. Gradually, Eddie acknowledged the fears that lay under his resentment: abstaining from drug use might lead to loneliness and loss of friendships; accepting his father�s rules meant losing his freedom and the adult image he craved. On a deeper level, Eddie�s distrust of his father stemmed from the divorce of six years earlier, when Eddie�s life was thrust into turmoil, his parents� needs seemed to take priority over his own.

In reframing trust-building as a task for Eddie as well as for his father, I was able to persuade Eddie to accept a series of agreements that included 1) submitting to urinalysis testing at his father�s request and 2) accepting material consequences (withholding of money, for example) whenever he relapsed. Having good intentions would not mitigate the consequences; if Eddie reached a �contact high� from someone else�s use, or received a positive drug test result after unwittingly tasting a drink that was �spiked,� the consequence would remain the same. When Eddie bristled: �That�s not fair,� I reminded him that his body and brain would respond the same to exposure to a drug regardless of his notions of fairness.

A second series of agreements presented a particular challenge to Mike. In conjoint therapy, Mike spoke of his feelings of guilt as a parent. His inconsistent parenting and controlling tendencies: name-calling, impulsive imposing of consequences, and distancing interpretations of his son�s behavior (�I think you use to escape from your feelings!�) masked a deep feeling that he and his ex-wife had let Eddie down. I suggested to Mike that he seemed as impulsive and conflicted as his son and that his behaviors were inadvertently reinforcing his son�s negative behaviors. I worked with Mike to focus on consistently and calmly following through on realistic limitsetting. Trust could not be based on an anxious belief in his son�s latest promise, only to be followed by blame. Father and son were to commit to eliminate bargaining over the fairness of consequences of the son�s drug use: the relapse of a friend, the father�s controlling behavior, or other stressors, could no longer justify relapse. Further, each committed to seek out separate support systems for the processing or venting their feelings, so that they could avoid directing judgements at each other.

These agreements allowed for father and son to understand that trust is a bond that develops and evolves through ongoing attention and care, not something to be taken for granted. They allowed father and son to navigate past mutual blame, and made space for each to sit with their uncertainty and discomfort � without resorting to substance use on the part of the son, or rigidity on the part of the father.

Over the course of therapy, there were relapses on either side. Eddie often tested his father�s curfews, demands for phone �check-ins,� and chore assignments; he used drugs on numerous occasions, and generally manifested his contempt for Mike�s parenting. Mike gave frequent voice to frustration, often characterizing his son�s relapses as a form of betrayal. As time passed, the structure provided by agreements allowed father and son to explore and change their values, and challenge the beliefs that perpetuate thecycle of drug addiction.

Mike and Eddie terminated therapy after about a year. At that time, Eddie had been clean for 90 days and wanted to focus more on twelvestep work. Mike has sent me Christmas cards the last three years, and Eddie has contacted me as well. Their relationship, though not perfect, has improved. Eddie has grown to see the connection between being truthful and gaining trust and is invested in truthfulness as a value for himself. Mike is more willing to take responsibility for his feelings of guilt and inadequacy, instead of externalizing them or blaming his son. Ultimately, Eddie moved out of his father�s house. Without the intensity of cohabitation, Eddie is more able to pursue the tasks of individuation, and Mike the task of letting go.

References

Gorski, T. (1989) Passages Through Recovery: An Action Plan for Preventing Relapse. Hazleton: Center City, Minnesota

Miller, M.& Bakalar, JD. �The adolescent brain: Beyond raging hormones.� The Harvard Mental Health Letter, July 2005, 22(1).

Graeme Daniels is the supervisor of the intern program at Thunder Road Adolescent Treatment Center, which specializes in substance abuse issues. He is in private practice in Pleasant Hill and has worked with adults, adolescents and families dealing with substance abuse for the past ten years. He can be reached at (925) 487-5934.

Note: This article reflects the opinions of the author and not necessarily those of
East Bay CAMFT.