Four years ago I set up the SWAN Project with a colleague. We now have about 20 students who do voluntary counselling for us while they are finishing studying for their counselling diplomas. We take students from a variety of universities, colleges and counselling and psychotherapy training centres.
I originally wrote this book to give to our students. It was a way of passing on quickly how we thought about alcohol misuse. There are no other projects or books which think about alcohol misuse in this way; 1) as being on the self-harm – self-care continuum, 2) which considers psychotherapy / counselling theory, 3) which considers body memory
What happened next was that I gave a copy to all the clients who had been participants in the project whose narratives I had used. I very quickly discovered that the clients themselves got a lot from the book even though it was written for a different audience. I have been in the process of rewriting it with this new audience in mind. I am just finishing the final part. It is called Addiction - Towards Recovery through understanding and self compassion. Hopefully it will be in the shops by 2008.
Using vignettes and actual case histories I present a clear, dense and compelling narrative. I expand upon theories taken from different orientations within psychotherapy, including body psychotherapy. I consider: what draws people to use addictive substances; how addictive substances serve the user; the conscious and possible unconscious reasons behind their use; which individuals are likely to be susceptible to developing an addictive habit and the part that shame and fear can play in an addict's life. There are two intimate stories provided by two individuals who describe their inner and outer worlds at the beginning of their recovery processes and I describe how they moved on in therapy. Finally I am in the process of writing a part on the myths and facts about moving on from addiction.
Scroll down for first chapter. CONTENTS
1The self-care – self-harm continuum
2Our place on the continuum – Part One
3Our place on the continuum – Part Two
4 Our state of mind
5 Our body story-lines and memory
6 Our shame process
7 Kevin's story
8 Michelle's story
Who am I?
I started my career as a teacher of children with learning difficulties. I have an MA in psychodynamic counselling from the University of Reading, a supervision diploma from Sherwood Psychotherapy Training Institute in Nottingham where I also trained as an integrative psychotherapist. I have studied body psychotherapy with Jochen Lude, co-founder of the Chiron Institute in London.
I set up and currently run the SWAN Project; an initiative focused upon addiction to alcohol and prescribed drugs, which is just about to receive charitable status. I am a visiting lecturer at Bristol University. I work as a supervisor and psychotherapist in private practice and I run training courses.
THE SELF-CARE AND SELF-HARM CONTINUUM.
Self-harm is “a purposeful, if morbid, act of self-help”Favazza (1989, quoted in Turp)As a term, we usually think of self-harm as behaviour confined to a small group of people who intentionally harm themselves, although most commonly it refers to cutting or some other form of self-maiming. Similarly when the term ‘self-harm' is used in relation to substance abuse it refers to the intentional act of consuming excessive amounts of a mood-altering drug, despite the knowledge that it will result in physical and/ or psychological self-injury. As the act of drinking, smoking, sniffing or injecting a drug is seen as purposeful and intentional, these acts often provoke strong emotional and critical responses from observers. However, the question that is not often considered is what purpose and intention these acts serve.
Turp (2003) understands general self-harm as an umbrella term for behaviour;
“1) that results, whether by commission or omission, in avoidable physical self-harm and 2 ) that breaches the limits of acceptable behaviour, as they apply at the place and time of enactment, and hence elicit a strong emotional response.” (p36)
Turp challenges the idea that the behaviour of people who ‘self-harm' is different from that of ‘normal' people, and instead invites us to think about self-harm as a continuum - that is on a line which describes our behaviour from “good-enough self-care” (for example, we might drink occasionally within the recommended health guidelines) to “compromised self-care” to “mild self-harm”, to “moderate self-harm” and finally to “severe self-harm” (for example, we drink more than recommended on a daily basis). Turp believes that we all have the potential to use self-harming behaviours and she points out that some self-harming activities are culturally acceptable, whereas others are not. (She uses the acronym CASHA to distinguish ‘culturally accepted self-harming acts or activities'.)
Whether these activities are acceptable or not seem to be more a question of how much they impact on others' lives, rather than how dangerous they are to the individual who is using the behaviour. Smoking used to be acceptable, but became less acceptable as society became more aware of its indirect impacts. By contrast, breaking the skin on your arm with a razor, although at one level is less harmful than smoking, is socially unacceptable because of the distress it imposes on the onlooker.
In terms of acceptability, mood altering drugs do not fit neatly into either the acceptable or unacceptable category. Whether it is acceptable or not depends partly on the quantity used and on the perception of the person making the value judgement. It remains socially acceptable to drink alcohol in moderation, but people who drink to excess and exhibit unsociable behaviour are shown an ever decreasing degree of tolerance. What is considered unacceptable behaviour also differs from social group to social group. For example, teenagers may find it abnormalnotto take Ecstasy when out clubbing, whereas a group of social drinkers might become embarrassed or critical if one of their friends gets too intoxicated.
Excessive use of mood-altering drugs and anti-social behaviour are closely linked. Excessive amounts of alcohol can result in anti-social behaviour and individuals with a drug habit often use anti-social behaviour in order to gain the finance to procure their drug of choice. As a result, shame surrounds many aspects of drug and alcohol abuse. However, research has shown that the greatest reason given for self-harming activities is the ‘relief of feelings' (Arnold, 1995, quoted in Turp, 2003). This finding fits with my own personal experience as a professional working with those who are addicted to a substance. I have not yet met anyone with an addictive habit who had not initially been using it to cope with their emotional difficulties. Once an addiction is established this underlying trigger is camouflaged by the habit, which develops due to the physical discomfort experienced when the drug is not available.
People often comment that they become ‘more confident', ‘less depressed', ‘more fun to be with', ‘less anxious', ‘less bored', and so on when they drink or take a particular drug. Many of these reasons have to do with anxiety – for example, social anxiety, so that you can feel more relaxed, confident in company. Boredom and depression we will return to later as they are not so much to do with anxiety, but as the result of a defence against it or other unpleasant emotions.
Most people start out as social drinkers or casual drug users. People who go on to become addicted to a substance are those who discover that it provides them with something they have not yet found anywhere else. If you use alcohol each time you mix socially because you feel anxious without it, you come to rely and depend upon it.
If our chosen form of dealing with our emotional upset is to use an addictive substance, we need ever increasing amounts in order to reach the same desired state. Weegmann (2003) makes the following comment:
“The immediate manifestation of its use may be one or several of the following: an alteration in mood, a rising in self esteem, an increased vitality or energy, a sense of power or assertion, an intense affective experience or a nullifying of intense experiences, taking the edge off reality. Temporarily, therefore, the taking in of the drug can lead to a feeling of triumph over problems within the self, however this constitutes a pyrrhic victory.” (p.36)
This battle, where the victor loses as much as he gains can be repeated endlessly because the affect of mood-altering substances easily confuses our brain in terms of cause and effect; the short-term consequences are perceived as good and beneficial, but we are not so conscious of the link between drinking or taking the drug and the long-term damaging effects. We might drink or use a drug to solve a particularly difficult situation and find that in the short-term that the substance works. What we are less able to add to the equation is the long-term effect of that usage – the physical and psychological cost that accrues as we become more reliant on the chosen drug and become increasingly less able to cope with day-to-day issues.
Most people have a tendency towards some form of self-harm when their level of emotional upset becomes too much or unbearable. Some of us bite our nails, pick at our fingers, pull our hair, eat cakes, smoke cigarettes, drink coffee, cut our arms, drink or take drugs. My clinical experience indicates that in part our chosen method of self-harm depends on the severity of our psychological distress. We adopt the behaviour that is at some level “good-enough” to relieve that distress - no matter how temporarily. Often during the course of treatment individuals will move from gross to less severe levels of self-harm.
FleurWhen Fleur came to therapy she had a history of an eating disorder and using drugs and drink. She came to see me at a time when she had given up hard drugs and was struggling to stay abstinent from alcohol. As we worked together, the frequency of her lapses lessened as she learnt from each one.The first lapse happened during a six-week break when Fleur had been away from home and her support; our project and her AA sponsor. It happened at a time when she had over-committed herself to support a group where she was a member. The actual trigger was conflict with another member of the group. Immediately after the incident, she drank a bottle of wine. She also had a few drinks over the following week. Reflecting on the incident later, Fleur was able to take on board the lack of support and the amount of stress she had put herself under.Another lapse came after she walked out of our session at exactly the same time that a paramedic, who had attended to Fleur after one of her suicide attempts, left the adjacent room, having attended to someone else. Fleur had an association between the ambulance crew, her various suicide attempts and being taken to a psychiatric ward. Even seeing an ambulance in the street brought up negative emotions in her body. This incident was more difficult for Fleur to cope with than the previous one so this time she drank two bottles of wine. She described it later as going onto “automatic pilot”. Although her mind was telling her that this was “stupid” and “not going to help”, it felt as if something stronger had propelled her toward the drinking.As Fleur used alcohol less and less, she used other less severe self-harming acts. She would occasionally comb her head until she broke the scalp, forget to eat breakfast and lunch but then eat junk food when her blood sugar was so low that she found it difficult to function, or forget to take her medication, and so on.As time went on, Fleur learned to be in touch with her feelings, to understand them, to sit with them and manage them. Although her lapses stopped, when Fleur became distressed she did sometimes resort to other self-harming behaviours, but they were less severe and less frequent.
These less severe forms of self-harm have been labelled “hidden self-harm” by Turp. Although a high percentage of the population use self-harming practices, minor cases are rarely brought to the attention of professionals, because on the whole they do not disrupt every-day lives, whereas a drug dependency often does. We can see that, as Fleur is more able to contain her own emotions, her self-harming practices become more hidden and so more socially acceptable. Turp, comparing what is normally thought of as self-harm with CASHAs, comments:
“There is a difference of intensity rather than one of kind. In other words,the difference resides in the level of desperation and emotional distress involved.” (p10)
Individuals sometimes have a sense about which particular form of self-harming behaviour will relieve a particular quality or essence of an emotional distress.
JaneJane had been to America to see her daughter. At the beginning of her flight home there was a thunderstorm and the plane was caught in turbulence. Her fear grew and she felt as though she was about to be obliterated, even though her mind told her otherwise. She found the situation unbearable and to cope with her anxiety, in what seemed like a death-threatening situation, she drank excessively.On the same trip, Jane's partner had been expected to collect her from the airport at a particular time, but at the arranged time he did not appear. From experience she knew that he always phoned if he was going to be delayed. She had trouble trying to make sense of what had happened to him, other than the thought that he must have been involved in an accident. Her anxiety rose as she fantasised about life without him and she found herself pacing the terminal, eating chips, biscuits and a chocolate bar. This time she did not go to the bar.
When we talked through these incidents, we noted that in the first situation her anxiety was for her own survival and in the second for another's. While trying to make sense of the two incidents, Jane realised that eating food on the plane would not have helped in the same way that the alcohol had. When her partner was absent and longed for, eating chips, biscuits and chocolate somehow helped her to feel that her partner was present: they filled an empty feeling inside her. This seems to be a common phenomenon possibly due to our early experience as babies. When we are being feed and so our stomachs are being filled, our mother is usually present. We start to associated the filling of our stomachs with a nurturing other being present. On the other hand, what was needed on the plane was not to fill an empty feeling, but to avoid being in the present moment. By drinking too much and not having to be present, she gained a sense of relief as her fear of crashing disappeared as she got increasingly intoxicated. We might then choose different self-harming activities for different types, as well as different levels of anxiety.
So we have seen that self-harming activities are something that we all have the capacity to do when our emotional arousal is greater than our capacity to deal with it. Being aware and remembering that this is normal human behaviour in circumstances when we are in pain, keeps to the forefront of our minds the pain and suffering that is being experienced by those drinking excessively or taking drugs habitually. If self-harming behaviour in general can be seen as the result of emotional distress, then the gross self-harm that results from excessive use of chemical substances reflects the severity and quality of the psychological distress. Once we look at self-harming in this more general way it is more difficult to maintain a self-critical stance and our compassion naturally opens towards ourselves and other individuals using substances.
TURP M. (2003)Hidden self-harm. Narratives from Psychotherapy.London: Jessica Kingsley Publishers Ltd