Getting Beyond Sobriety

Clinical Approaches to Long-Term Recovery

Michael C. Clemmens

• Publisher: Gestalt Press
• Year: 2014
• ISBN:
  9781317706991
• Edition: 1
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

In this ground-breaking book, Michael Clemmens offers a new model of treatment for long-term recovery which goes beyond the traditional "disease" paradigm. Working from the belief that a fuller life for the recovering addict is grounded on a foundation of abstinence, the author explores a "self-modulation" approach which leads to a change in the behavior from within the individual while developing and expanding connection with others.

CHAPTER ONE
Addiction and Gestalt Therapy

This chapter presents a new model of addiction and recovery, the self-modulation model, contrasting this approach with the disease model, which is currently the most commonly used model in the treatment of addiction. It also presents the Gestalt approach to addiction and recovery employed throughout this book, which emphasizes the process of self-modulation from addiction through recovery. The patterns an individual develops before and during addiction change in recovery, being replaced by new patterns of behavior, new means of self-modulation. If we are to fully appreciate an addict's struggles during recovery, it is essential to frame the addict's changes in the context of previously developed patterns.

The Disease Model

As described by Stanton Peele, the dominant model in the treatment of addiction is the disease model. It is rooted in the literature of Alcoholics Anonymous and described in the Diagnostic and Statistical Manual of the American Psychiatric Association as a progressive series of identifiable behaviors, including both alcohol or drug use and decreasing social functioning. One particular advantage of this model is that to describe addiction as an "it" lessens the addict's sense of shame. The addict is not described as bad but rather as suffering from a disease. Current research supports genetic correlates for addiction.

My intention here is not to dispute genetic predisposition but to help avoid the blurring of personal responsibility. If we understand addiction only as a genetic disease, we may fail to examine the possible limitations of the current style of treatment. Moreover, as therapists, we perhaps interfere with the important step in recovery of the addict's assuming responsibility for his or her own behavior.

There is a still larger problem with the disease model, or with any model of human development not based on the lived experience of subjects. The disease model is a categorical construct, an interpretation of behavior in terms of the previously existing framework of physical illnesses. This approach to addicts' behavior helps create an entity that is separate from the addict, a kind of lurking germ that may emerge at any moment to make the addict use drugs or alcohol. Such a projection can lead clinicians and recovering addicts away from a focus on behavior, meaning-making, and choices, and instead toward a focus on determining who has the disease.

The Self-Modulation Model

Despite hunger, poverty, the threatened loss of family, job, or even life, addicts organize their experience around drug use to the virtual exclusion of all other interests and responsibilities. From a Gestalt perspective, the drug or drink remains dominant in the addict's awareness and is never finished or closed. Even when an addict is abstinent, the drug or other forms of desensitization continue to dominate. It is as if drinking or getting high is the only thing that matters to the addict; this exclusive relationship with the drug is the definition of addiction. While some addicts may not outwardly appear to be so focused on their drug, it is in fact the priority in their lives, after which they attend to other life issues.

This model is my attempt to provide what Elaine Kepner and Lois Brien call a "behavioristic phenomenology," a description of an addict's behavior as well as the meaning of that behavior. This model can thus provide both the "what" and the "what for" of addiction and recovery. It is a description of the progression of addiction as a process of self-modulation: how the addict modulates his or her own behavior. Through this regulation of behavior, addicts influence both their own experience and that of others. To view addiction as a self-modulation is to understand that it serves the addict in some ways, one of which is that individuals can influence and alter the sensations they experience, thus avoiding certain experiences that they find undesirable. Other ways that the addict's process serves him or her include ease in accomplishing tasks that might otherwise be difficult, a sustained sense of confluence or connection with others, and a sustained sense of self that feels coherent and integrated. These advantages can be perceived in the actual descriptions of active and recovering addicts.

The second aspect of the self-modulation model is my attempt to describe the addict's continuation of behaviors that appear to have diminishing returns. Addicts' persistence in using the same process (intoxication) results in a narrowing of their experienced world, a movement that has enormous negative impact on their interpersonal lives. This downside of chronic intoxication is what we usually define as addiction.

What then is the upside or advantage of the addict's persisting in a pattern of intoxication despite the subsequent narrowing of life experience? Often the ongoing preferred result for the addict is maintenance of the state of intoxication. Another way to put it is that addicts have a relationship with the drug that they know, value, and identify with, as with an interpersonal relationship. As one of my clients said of his choice of narcotics, "It's my wife and my life." The nature of this relationship is crucial in understanding and working with addicts in therapy. Without the perspective of self-modulation, any addict's behavior seems either to be a meaningless dysfunction or the symptom of some disease; the tasks of recovery, therefore, seem only remedial steps in changing the problem, rather than steps toward the development of contact skills and expanding levels of interpersonal relationship.

Being based on field theory, this model addresses differences among addicts as well as differences in field conditions not usually attended to in the disease model. According to Gordon Wheeler, field theory is a concept of Gestalt psychology that maintains that we experience our awareness within the larger field or environment that is already moving and changing. This larger environment includes other people, our present social, familial, or political situation, and other environmental conditions. But the individual organizes this held based on his or her need. This organization of the field is also based on the individual's development, personality, and individual factors. A ten-year-old boy and a thirty-year-old alcoholic organize the field of a bar in different ways. The boy focuses on and sees the bag of pretzels and the bright colors of the jukebox; the alcoholic focuses on and sees the bottles behind the bar, feels his thirst, and moves directly to the bar to order a drink. Because addicts vary in personality, developmental growth, age, gender, and other individual factors, the self-modulation model can help clarify how these differences organize the fields of both addiction and recovery. It will allow us to work with each addict individually, appreciating the unique intrapersonal and interpersonal struggles of each. These individual differences provide a context that can enlighten our understanding of the addict as a unique person, embedded in a life history and a relational world.

Finally, the self-modulation model describes the progression of addiction as a powerful influence on the addict. This allows us to consider how the addict's use of drugs may influence that person's level of functioning in recovery. What this adds to our understanding as therapists is that we recognize stages of recovery as an incremental restoration and development of the addict's social and psychological integration.

Overview of Gestalt Therapy

While there have recently been some efforts to describe a Gestalt perspective in working with addiction, the literature of Gestalt therapy overall has devoted minimal attention to addiction treatment. Frederick Perls, Ralph Hefferline, and Paul Goodman saw alcoholism as muscularly anchored in oral development. They describe the drinker is wanting to drink his or her environment in, to "get easy and total influence without the excitement (which to them is a painful effort) of contacting, destroying and assimilating." What does this intense and mechanical description mean? Perls and his colleagues were describing how addicts try to experience familiarity and comfort (confluence) without getting to know other people. This process of entering into novel situations, of meeting new people and thereby taking risks, is one that is by nature stimulating—emotionally, cognitively, and physically. Making contact involves listening, agreeing or disagreeing, noticing differences, and coming to experience both ourselves and others. Addicts, when using and in recovery, often try to avoid the experience of stimulation, sensing it as discomfort. Part of this pattern can result in a rush to reach familiarity.

The theory and practice of Gestalt therapy offer two options to addiction treatment that can be most useful. First, Gestalt therapy is a therapy of boundaries, one that focuses on the self-environment boundary as well as on boundaries within the self (split-off parts or polarities). This emphasis supports our observing the individual addict through different developmental stages of recovery and normal maturation. Psychological and emotional development is seen as a sequence or evolution of differing boundary relationships such as self-physical environment, self-parent, self-peers.

Second, Gestalt therapy views behavior as self-modulation, a view that allows us to understand the addict's behavior as useful in some manner, it is not only a potentially self-destructive habituation, it is also a coping style, a creative adjustment that enables addicts to tolerate stressful experiences. These experiences may be interpersonal or interactive, such as job interviews, first meetings in a social context, or conflicts with family members. They may also be intrapersonal, primarily within the self, such as facing painful memories or experiencing sadness or frustration. In addiction, this process, which starts as a useful modulation, develops into a pattern of behavior for its own sake. That is, the addict develops the pattern of using drugs so that the reasons for the drug's usefulness cease to be part of the user's awareness, until eventually his or her awareness is only of the drug itself. It is only when the addict stops using that the previously avoided feelings and situations are again experienced.

Organismic Self-Regulation

In Gestalt therapy, the term organismic self-regulation denotes the process of our recognizing what is most useful to us in any given situation and of choosing to act or not act on that recognition. We organize our perceptual, cognitive, and kinesthetic experience into meaningful and needful wholes or figures. In normal functioning, this organizing process leads us to the figures that are most useful to us. For example, when hungry we may think of restaurants that serve the type of food we crave, and we crave the food that satisfies whatever nutrients we need. Thus, what is figural—what stands out for us more sharply than all other possible figures—is ideally what we require in the moment.

In addiction, the organic process of feeling or seeing what is most necessary becomes skewed. Instead, the alcohol or drug becomes fixed as the uppermost figure in the addict's experience, to the exclusion of other relevant needs, impeding and possibly halting social and emotional development. In fact, other figures are not salient; the addict does not see them. The addict craves drugs when hungry, alcohol when desiring companionship, and cocaine when needing to pay the bills. This is the nature of addiction, to eventually blot out the rest of life. But the addict's focus on the drug is also based on a need: the need to maintain self and a particular frame of meaning. As J. Richard White describes, addiction is both "an attempt at survival, specifically spiritual survival" and "a desire for a meaningful life." My experience of working with addicts is that people who become addicted are seeking something more than daily existence, but they end up lost and unable to achieve that which they pursue. By their choice of a drug solution, addicts limit their own horizons and possibilities. I believe it is our task, as therapists working with addicts, to appreciate not only the limiting aspects of the addict's relationship with drugs, but also the meaningful survival functions such a relationship creates. This perspective will allow us greater vision in working with contact issues in recovery.

The Gestalt approach to addiction is based on three observations: First, addiction is defined as the addict's exclusive relationship with the drug, making other relationships or contact secondary and peripheral. Second, this relationship that the addict has with the drug both serves as an avoidance of other sensations and constitutes an attempt at meaningful survival. And third, any approach to working with addicts needs to address both the meaning of the addict's survival behavior and the metapattern of avoiding fuller contact with the self and the environment.

I want to present several principles of Gestalt therapy as frameworks for illuminating the process of addiction and recovery. They are process and descriptive principles rather than content oriented. In addiction and recovery, the drug is the content, and patterns of behavior are the processes that need to be supported or altered. What I believe to be more important is what the addict does, what that action accomplishes and means for him or her. Attending to the addict's process provides us with access to these behaviors and meanings. In working with addicts in long-term recovery, we often see that the drug or drink may be absent but the individual's process may continue unchecked, leading almost inevitably to relapse into overt addictive behavior.

Cycle of Experience

In identifying this metapattern of drug use as the dominant interest (or figure) for addicts, I have found it useful to work with the process by which this constant desire or thought occurs. This fixed pattern is what differentiates the addict from the nonaddict—from someone who is hungry and eats rather than drinks, who opens a bill and pays it rather than using drugs. A useful model for illustrating this development of a rising need (figure) and its resulting behavioral action is the cycle of experience as developed by Joseph Zinker and others at the Gestalt Institute of Cleveland. We can see the cycle in its uninterrupted form as a continuous movement from ground to figure and back again to ground, from vague sensation to specific object of attention and from increasing to decreasing flow of energy. Two examples of this cycle will provide clarification:

A man is watching television and begins to feel a vague gnawing sensation in his stomach. He initially ignores the sensation, but soon feels it again and recognizes it as hunger. He thinks to himself, "I am hungry." He wonders what he might eat and begins to picture a piece of chicken in his refrigerator. He moves to the kitchen, opens the refrigerator, and takes out the chicken. As he eats the chicken, his stomach muscles relax and he eventually feels full. He sits back down in front of the television, his feeling of hunger having passed, and his attention returns to the movie.

A woman is going through a stack of photographs. She sifts through them casually until she comes across the photo of a friend who recently died of cancer. As she looks at the photo, her breathing deepens and she feels her throat tighten. She feels as if she can't put down the photo; it is the sole object of her attention. Beginning to cry, she stares at the photograph, and whispers under her breath, "Oh Mary, I miss you!" She weeps more fully, relaxing her throat. Feeling as if she needs to talk to someone, to not be alone with this ...