A plea for the psychological needs to be given equal status with behavioural, cognitive and practical need for individuals who abuse substances/ alcohol.
Compassion - towards well-being and away from stigma.
Gilbert’s (2005) relatively recent research on compassion suggests that self-compassion leads to happiness, self-acceptance and well-being. He defines compassion as including empathy, sympathy, warmth and forgiveness. The experience of those who misuse substances lacks compassion from society at large and self-compassion. This makes Gilbert’s research seem very relevant. While the drug and alcohol strategy is under review this seems a good time to start a debate about how we can encourage our client group to have more self-compassion and how we can engender compassion for them in the rest of society.
My experience has been that workers are generally very compassionate because they experience the degree of psychological distress experienced by their clients, but the level of this distress is not reflected in the services offered. The treatment provision we offer seems to have goals which include meeting behavioural, cognitive and practical needs with a small gesture towards psychological needs. The word ‘rehabilitation’ focuses on changing dysfunctional behaviours and so our clients are seen as people who need to have their behaviour changed, rather than individuals who are overwhelmed by distress using a coping strategy that has led them to habitual using/drinking. If provision focused equally on the psychological needs of our service users, acknowledging and reflecting the psychological distress I believe it would have a profound effect on how our service users are seen by society at large and maybe more importantly by secondary services like the police and hospital staff.
For too long have people who used substances have been seen as a separate group, different to the rest of the population with mental health problems. Why have we, as service providers and as a society at large given such little attention to the psychological aspect of this client group? Historically, talking therapies were not seen as useful with this client group partly because the only one that was available was psychoanalytic psychotherapy. There are several reasons why psychoanalytical psychotherapy did not work and would still not work with this client group whereas other forms of talking therapies do .At the same time, the Twelve Step programme has been and is seen as specifically designed for to help people achieve and maintain sobriety. It has done this relatively successfully.
The unfortunate consequence of these two factors is that this historical legacy has meant that not only has society come to see substance mis-users as different and apart from other individuals with mental health problems but it also has left the heirloom of a treatment provision which views the mis-use as the only problem to be corrected rather than viewing the mis-use as a symptom of the underlying psychological distress which also needs attention.
What is common knowledge, to anyone working within services, is that the mis-use is too often only an acting out of psychological difficulties. To put it another way, substance mis-use is often a coping strategy, a crutch, in the same way someone else might use the distraction of over work to counteract difficult feelings.
A different approach would be to acknowledge that self-harming activities are a natural response to a situation when human beings have more anxiety/ stress than they can cope with. These activities exist on a continuum from less to more harmful behaviours which include: biting nails, pulling hair out, drinking too much coffee/tea, working too hard, exercising too vigorously, smoking, drinking, using other substances and suicide to name a few. Some of these behaviours are culturally acceptable and others are not. Turp’s (2003) work on self-harm normalises self-harming activities. It is easy for anyone working in the field to relate this to anyone drinking excessive amounts of alcohol and/or using other substances.
While seeing self-harming activities as a behaviour that many of us use to deal with unmanageable emotions, Turp points out that the severity of the self-harming activity is related to the amount of unmanageable emotional distress that is felt. Turp’s model of a self-care – self-harm continuum, with minor self harming activities at one end and suicide at the other extreme, provides us with a structure from which to gauge the distress of substance mis-users. Many substance mis-users have extremely high degrees of distress so any psychological intervention would need to be long-term.
Counselling is multi-faceted and different aspects of it are used according to where someone sits on the Cycle of Change ( Prochaska J.O., Diclemente C.C. & Norcross J.C. 1992). While someone is still drinking, for example, counselling focuses on collecting information about the amount being consumed while linking it with thoughts and actions that are occurring at the time, identifying cues and triggers, exploring strategies to help break habits and helping to construct manageable plans to cut back or stop. Once the client is abstinent or has reached his/her desired goal counselling can support the client to come up with plans to get through the next few hours/ days, exploring ways to cope with difficult situations and generally to prevent a lapse. All these things can be done very effectively working short-term. However, this has its limitations as the service user is still left with the issues that underlie his/her addictive habit.
Maybe treatment plans have given too much priority to focusing on the environment almost exclusively – their external world - to keep our service users safe without looking enough at what is going on in their internal worlds – their perceptions, how they experience situations and relationships. It is easy for an addict to remain on the straight a narrow while they are in a residential rehab, attending a day programme or living in supported housing. Their anxiety levels will remain low as their feelings are being contained - made manageable - by the perceived support. However, when they leave the safe environment how can they manage their feelings if they become overwhelming without regressing back to old strategies of using or drinking which worked for them in the past, unless they have learnt how to self-soothe?
The work of Schore (2001) and Gerhardt (2004) on neuro-science suggest that long-term counselling which provides repeated experiences of containment, of emotional soothing can open new neural pathways which enables the experiences to become internalised eventually giving the service user the ability to self-soothe. Also by working through the issues that are underlying the using the amount of unprocessed, overwhelming thoughts and experiences are diminished.
It appears that it would be beneficial if provision included at least one long-term compassionate relationship which supported the service user’s journey through all the different modalities provided. Maybe we need to put more emphasis on addressing the underlying, often psychological issues that are more often than not at the bottom of the substance mis-use. Long-term talking therapies could be put in place to work in conjunction with and along side the services we now provide. In that way we would be making a statement about this client group, about their vulnerability, to society at large.
By moving our focus to include addressing the underlying issues, rather than just the symptoms of the substance misuse - the unacceptable behaviour - compassion is able to flow. When the underlying issues are addressed and resolved service users experience empathy and compassion and they are empowered by increasing their self-awareness and enhancing their decision making abilities.
It is probably true that the services that are commissioned and the attitudes of society reflect each other. The coping strategy of this client group is culturally unacceptable and services appear have as their only goal the cessation or limiting of this behaviour. In this way service design flows from societal attitudes and in turn influences them. It seems that currently society is unable to be compassionate towards our client group because the focus is on behaviour rather than the distress which is covered up by that behaviour. This lack of compassion from society is very much at odds with the attitude of the workers in the organizations which provide the services. Workers who have the privilege of developing intimate relationships with service users; who hear their stories and see the degree of their distress are generally full of compassion. The experience of working with this very vulnerable client group brings an understanding of the importance of consistency, continuity and long-term work - both at a practical and psychological level. However, recently more and more of the vital work that is commissioned has been limited to short-term work within one modality of provision.
All counselling/ psychotherapy research shows that it is the relationship that heals, rather than any particular orientation of counselling. This must surely be true for our work too. One long-term therapeutic relationship can achieve more healing than a series of short-term ones. If models of relating can over a long period of time become internalized, it therefore follows that a long-term compassionate relationship could facilitate service users to become self-compassionate bringing happiness, self-acceptance and well-being. Maybe we need to start acknowledging that our very vulnerable service users can not be healed by a quick fix here and a quick fix there!
GILBERT P. & PROCTER S. (2005) Compassionate Mind training for people with high shame and self-criticism: Overview and pilot study of a group therapy approach. Submitted to Clinical Psychology and Psychotherapy on 22.8.2005Gilbert
GERHARDT S. (2004) Why Love Matters –How affection shapes a baby’s brain. London: Routledge
GILBERT P. (2001) Evolutionary approaches to psychopathology: the role of natural defences. In Australian and New Zealand Journal of Psychiatry. vol . 35, pp17-27.
PROCHASKA J.O. & DICLEMENTE C.C. & NORCROSS J.C. (1992) In search of how people change. Applications to addictive behaviors. In American Psychologist. 47, (9) pp1102-111
SCHORE A. (2001) The Effects of Early Relational Trauma on Right Brain Development, Affect Regulation, and Infant Mental Health.’ Infant Mental Health Journal. Volume 22, 1,pp 201-269.
TURP M. (2003) Hidden self-harm. Narratives from Psychotherapy. London: Jessica Kingsley Publishers Ltd.
Ronnie Aaronson is a UKCP accredited psychotherapist, co-founder and co-project leader of the SWAN Project in Bristol, which is a sustainable project providing low-cost long-term counselling for anyone in recovery, and a supervisor in several other alcohol and drug agencies. Contact: firstname.lastname@example.org
 See AARONSON R> (2006) Addiction – this being human Authorhouse. Milton Keynes