Category: Alcoholism

Understanding Sexual Reenactments and How to Eliminate Them

Posted on by rezendevknowfully.com

In general, reenactments are an unconscious attempt to reconcile, reframe, or repair a trauma that occurred in childhood. Sexual reenactments are no different. Most sexual reenactments originate due to childhood sexual abuse or sexual assault in adolescence or adulthood. Although not every former victim of sexual violence will have a need to reenact their trauma, many do. This is because most sexual trauma goes unprocessed. Most sexual abuse victims don’t talk about it due to feelings of shame and the fear that they will not be believed. Many try to put it in the past the way friends and family encourage them to do. Unfortunately, this doesn’t work, and they end up reenacting the abuse in some way. As it is with other forms of abuse, typically, former victims tend to either reenact their trauma by continuing to be victimized or by becoming abusive.

It is common knowledge that victims of child sexual abuse have a tendency to reenact their trauma by being re-victimized throughout their lives, by repeating what was done to them and thus becoming an abuser, or by becoming promiscuous or sexually addicted. In this article I will discuss all of these types of sexual reenactment.

Patterns of Re-Victimization

Research over the past decade has consistently shown that women who were sexually victimized as a child or adolescent are far more likely to be sexually assaulted as an adult than other women. One study found that former victims of CSA are 35 times more likely to be sexually assaulted than non-victims. (1)

In addition, reenactments often lead to re-victimization and with it, related feelings of shame, helplessness, and hopelessness. For example, it has been found that women who were sexually abused as children are more likely to be sexually or physically abused in their marriages. Therefore, helping clients gain an understanding and control of reenactments is a primary way to help them avoid further victimization and shaming.

Why are victims of child sexual abuse more at risk of being re-victimized?     

  • Most former victims of child sexual abuse experience a lot of shame and self-blame. These two factors are by far the most damaging effects of CSA and increase the likelihood of re-victimization more than any other effect. This is partly true because victims of sexual abuse develop certain behavioral problems, such as alcohol abuse, that make re-victimization more likely. Victimized women, in particular, believe that they have brought any abuse they’ve experienced on themselves and that they do not deserve to be treated with respect or loved unconditionally. (2) Furthermore, shame is related to an avoidant coping style, as the person who is shame-prone will be motivated to avoid thoughts and situations that elicit this painful emotional state. A victim who is experiencing avoidant symptoms may be prone to making inaccurate or uninformed decisions regarding potential danger because of the fact that the trauma has been denied, minimized, or otherwise not fully integrated. (3)   
  • They tend to have alcohol and drug problems. Former victims often numb their re-experiencing symptoms with alcohol and drug use, which can serve to impair judgment and defensive strategies. According to research, former victims of child sexual abuse are about 4 times more likely to develop symptoms of drug abuse, and adolescents who have been sexually abused were 2 to 3 times more likely to have alcohol use/dependence problems than non-victims CSA has also been identified as a significant precursor to alcohol abuse. (4)  
  • Certain factors increase the likelihood of re-victimization. Factors such as the severity of the abuse, the use of force and threats, whether there was penetration, the duration of the abuse, and closeness of the relationship between victim and offender are associated with higher risk of re-victimization. (5) 
  • Certain kinds of abusive men target women whom they perceive as vulnerable. These men can easily spot a vulnerable woman just by observing their posture, the way they walk, and the way they speak.  
  • Former victims tend to have sexual behavior problems and oversexualized behavior. Children who have been sexually abused have over 3 times as many sexual behavior problems as children who have not been abused.
  • They tend to have low self-esteem and poor body image. Obesity and eating disorders are more common in women who have a history of child sexual abuse. Girls and women who have a poor body image are more likely to feel complimented by male attention and are more vulnerable to men taking advantage of their need for attention.
  • They may feel powerless because the abuser has repeatedly violated their body and acted against their will through coercion and manipulation. When someone attempts to sexually violate them as an adult, they may feel helpless and powerless to defend themselves.
  • They don’t tend to respect their bodies. They may feel stigmatized, suffer from a great deal of shame and feel like they are already “damaged goods,” and there is no point in protecting their reputation or their body.
  • They don’t tend to be attuned to warning signs that a person may be a sexual perpetrator.  
  • They don’t tend to have good boundaries. Former victims often allow other people to have too much access to their body, to take direction and advice too readily, to have difficulties saying “no.” 

My client Ellen was re-victimized many times, by several different men and for many of the reasons stated above, specifically, shame and self-blame, being targeted by abusive men, feelings of powerlessness, a lack of respect for her own body, and poor boundaries.

“Starting when I was seven years old, my uncle began grooming me. My parents had just divorced, and my uncle started taking me places—supposedly to make up for the fact that my dad stopped coming to see me. He’d take me to the zoo, the park, and to the movies. He bought me candy and popcorn and sodas. And he bought me comics—I was really into comics. He was always very affectionate towards me, and I welcomed it because I missed my father so much.

“His affection gradually turned into sexual touches. It felt good so I didn’t resist. He progressed from touching my vagina to inserting his finger and then inserting other objects. At that point I didn’t like it. I didn’t get any pleasure—in fact when the objects got bigger it began to hurt. But I couldn’t say anything. He’d done so much for me, and I loved him so much that I just took it. Sometimes it hurt so much that it made me cry. He just ignored my crying and kept on doing it.

“I realize now that I have been reenacting the horrible abuse I experienced at the hands of my uncle for quite some time now. I’m so embarrassed to even tell you what I’ve allowed men to do to me. I was involved with one guy who was deep into BDSM (Bondage, Discipline, Sado-masochism) and I ended up letting him tie me up, drop hot candle wax on my vagina, insert objects into my anus. You’d be shocked if I showed you the number of scars I have because of that relationship. At the time I convinced myself that I loved him and because of that, I wanted to please him. But in actuality, I was just blindly repeating what my uncle did to me.”

Abuser Patterns

Just as not every former victim of CSA develops a victim pattern, not every former victim becomes an abuser. But unfortunately, many do. There is quite a lot of controversy about the extent to which males victims, in particular, repeat the abuse they suffered. Collecting reliable data has been difficult since subjects are not always willing to reveal their earlier childhood experiences, nor their own perpetrator behavior.

It appears that the type of sexual abuse one experiences can be a factor in the likelihood of becoming an abuser. For example, the evidence shows that only 21% of incest victims become sexual predators, whereas being a reported victim of pedophilia is strongly linked with being subsequently a perpetrator of pedophilia, alone or jointly with incest, with the combined rate being 43%. (6)   

Several studies were conducted assessing the rate of child sexual abuse reported by 1717 male perpetrators of sexual assault who had admitted their crimes. The researchers were able to determine that, overall, 23% of the perpetrators had experienced sexual abuse with physical contact in childhood. (7) More recently, other studies have indicated that child sexual abusers are much more likely to have been sexually victimized as children compared not only to people who sexually assault adults, but also to non-sexual criminals and the general population.

Several studies have examined the factors that may increase the risk that male victims of child sexual abuse will go on to commit sexual assault. The key factors are:

In childhood:   

  • Severity of the sexual abuse (more than one perpetrator, use of violence, greater frequency, longer duration, significant relationship with the perpetrator, etc.)
  • Sexual abuse committed by a woman
  • Positive perception of the sexual abuse experienced (positive affection for the perpetrator, perceived pleasure, poor understanding of the negative effects of the abuse, etc.)
  • Limited emotional support from family and friends during childhood
  • Intimidation and few meaningful social contacts during childhood and adolescence
  • Maltreatment
  • Lack of parental supervision
  • Adjustment difficulties and mental health problems in childhood and adolescence  

In adulthood:

  • Limited awareness of the difficulties associated with having experienced sexual abuse in childhood
  • Low self-esteem
  • Antisocial behavior (8)  

What Do These Findings Tell Us?

  • Experts maintain that, in the case of males, being sexually abused in childhood is an important risk factor for committing sexual assault later on in life, but that it is not the only risk factor that plays a role in the perpetuation of sexual assault.
  • Most victims of child sexual abuse will not become perpetrators of sexual assault, and a history of sexual victimization is neither a necessary nor a sufficient condition to sexually offend.
  • Personal and family factors in childhood that have been identified as increasing the risk that a sexually abused child will go on to commit sexual assault suggest that children who obtain specialized treatment, sufficient support from family and friends, and grow up in an environment where they do not experience maltreatment are less likely to develop a number of problems, including sexually aggressive behavior.  
  • Individuals who do offend had, among other things, more problems in childhood and were unaware of the negative effects of the sexual abuse they suffered.

The bottom line is, if someone was sexually abused in childhood or adolescence, they need to:

  • Admit the abuse to themselves.
  • Learn about the possible effects it can have on someone, especially in terms of their sexual attractions, their sexual relationships, the amount of anger they still have toward their perpetrator and how they act out this anger sexually.
  • Learn what their specific triggers are—those reactions that can cause them to not only remember the abuse but to act out in a negative or even dangerous way.
  • Focus on what their unfinished business might be so that they are not motivated to reenact the trauma.  

What’s at the Core of Sexual Reenactments?

Reenactments are always an attempt to manage unprocessed trauma. But in addition, sexual reenactments can be the following:

  • An unconscious attempt to come out of denial and face the truth about what happened to you
  • A cry for help
  • An attempt to take back a sense of power and control
  • A reaction to being triggered
  • An attempt to understand what happened to you  

Let’s discuss each of these reasons one by one.

An Unconscious Attempt to Come Out of Denial

As I’ve have been discussing, reenactments are caused in part by powerful unconscious forces that must be eventually verbalized and understood. These patterns of behavior are often unconscious attempts to reconcile, reframe, or repair the abuse that occurred in childhood. Unfortunately, they do not always accomplish this task and can result in perpetual psychological and emotional damage. The primary reason why it is important for former victims to acknowledge the sexual abuse is that those who are in denial are particularly vulnerable to sexual reenactments.  

One of the main reasons why victims of CSA continue to be re-victimized is that they are either in denial about the fact that they were sexually abused, they have minimized the damage caused by such abuse, or they convince themselves that they are not at risk. Let’s return to Ellen, the woman who was frequently sexually mistreated by men and who allowed a boyfriend to repeat what her uncle had done to her. In Ellen’s case, she had never denied that her uncle had molested her. But she did struggle to believe that he never cared about her, that he was just using her. “Even though he did terrible things to me sexually, he had originally been so good to me that I tried to excuse the other stuff. I continued to believe that if I let him do the bad stuff, he’d become the “good Uncle” again. I must have had the same thinking process with all those men who did horrible things to me. By reenacting the abuse by my uncle, in a weird way I was actually forcing myself to admit that he never really loved me, something I needed to face.”

It’s critical to help clients acknowledge whether they were sexually abused as a child or not. Child sexual abuse includes any contact between an adult and a child, or an older child and a younger child, for the purposes of sexual stimulation of either the child or the adult or older child and that results in sexual gratification for the older person. This can range from non-touching offenses, such as exhibitionism and child pornography, to fondling, penetration, incest and child prostitution. A child does not have to be touched to be molested.

Many people think of childhood sexual abuse as being an adult molesting a child. But childhood sexual abuse also includes an older child molesting a younger child. By definition, an older child is usually two years or older than the younger child but even an age difference of one year can have tremendous power implications. For example, an older brother is almost always seen as an authority figure, especially if he is left “in charge” when their parents are away. The younger sibling tends to go along with what the older sibling wants to do out of fear or out of a need to please. There are also cases where the older sister is the aggressor, although this does not happen as often. In cases of sibling incest, the greater the age difference, the greater the betrayal of trust, and the more violent the incest tends to be.

Many former victims do not realize that what happened to them as a child or adolescent was considered abuse because their image of child sexual abuse is limited to an older man abusing a child of the opposite sex. But this does not take into account males who are victimized by another male, those who were abused by a female, victims of sibling abuse, and victims of clergy abuse.

Also, in addition to the actions that we normally consider to be childhood sexual abuse, there are many other behaviors that fall into this category. You may wish to provide your clients with the following questionnaire, following questionnaire, from Put Your Past in the Past: Why You May Be Reenacting Your Trauma and How to Stop.   

Questionnaire: Were You Sexually Abused?

Did a family member, a caretaker, a sibling or other older child, an authority figure or any other adult or older child:  

1. Lie or sit around nude in a sexually provocative way?
2. Walk around the house in a sexually provocative way (nude, half dressed)?
3. Frequently walk in on you while you were getting dressed, while taking a bath or while using the toilet?
4. Flirt with you or engage in provocative behavior such as making comments about the way your body was developing?
5. Show you pornographic pictures or movies?
6. Kiss, hold, or touch you inappropriately?
7. Touch, bite, or fondle your sexual parts?
8. Make you engage in forced or mutual masturbation?
9. Give you enemas or douches for no medical reason?
10. Wash or scrub your genitals well after you were capable of doing so on your own?
11. Become preoccupied with the cleanliness of your genitals, scrub your genitals until they were raw, tell you that your genitals were dirty, shameful or evil?
12. Force you to observe or participate in adult bathing, undressing, toilet, or sexual activities?
13. Force you to be nude in front of others? Force you to attend parties where adults were nude?
14. Peek at you when you were in the shower or on the toilet, insist on an “open door” policy so they could walk in on you at any time in the bathroom or in your bedroom?
15. Make you share your parents’ bed when you were old enough to have your own bed (assuming other beds were available)?
16. Have sex in front of you after you were old enough to be upset, confused, or aroused by it?
17. Tell you details about their sexual behavior or about their sexual parts?
18. Take photographs of you nude or engaged in sexual activities (once again, after you were old enough to be embarrassed by it)?
19. After you reached adolescence or older, ask you to tell them about inappropriate details about your sexual life.
20. Allow you to be sexually molested without trying to stop it?
21. Deliver you to other people so that they could molest or rape you, or bring people over to the house who would molest or rape you?
22. Make you into a child prostitute?
23. Continue to make sexually inappropriate comments, or to touch you in sexually provocative ways even after you reached adulthood?  

A Cry for Help

Often, without realizing it, former victims of CSA put themselves in dangerous situations as a way of letting others know they need help. They behave recklessly, get in trouble with the law, drink too much, take drugs, and/or associate with dangerous people. Coming back to Ellen, another reason for her reenactment was that she was crying out for help—not on a conscious level of course, but on an unconscious one. Although she was ashamed of all her “battle scars,” they too were cries for help. In fact, she later admitted that she often wore short sleeves so people would see her scars and ask her about them.  

In most situations, if you were to confront former victims about the risks they take, they will deny it, but there is no doubt about it, in spite of their protests to the contrary, they are desperately crying out for help. This was the case with my client, Caitlin:

“When I was a teenager I got into all kinds of trouble, from shoplifting to overdosing on drugs. My parents were exasperated—trying to control me, trying to make me understand the danger I was putting myself in. But frankly, I just didn’t care. I didn’t care what happened to me.

“Now I understand that I was calling out for help. I wanted my parents to know how much I was hurt and why. I was being molested by my grandfather, a man my parents adored, and because they adored him, I couldn’t say anything. I didn’t want to break their hearts if they realized what a monster he actually was, and I didn’t think they would believe me anyway. It was like I was waving a giant red flag saying, ‘Hey, look at me. See how much I’m hurting. Try to figure out why.’ But they never did, and I just got worse and worse.

“Eventually, I got involved with a guy who was basically a gangster. He and his friends robbed liquor stores, but he pretended to be a nice guy. He’d come to my house to pick me up and be all nice and polite to my parents. He had them fooled completely, just like my grandfather had them fooled. Talk about a reenactment.”

An Attempt to Take Back Power and Control
Another common reaction to child sexual abuse is to attempt to regain a sense of power and control over one’s sexuality. Perhaps the best example of this is when former victims of CSA become prostitutes or strippers. There have been numerous studies showing that a majority of prostitutes were sexually abused as children or adolescents (8, 9). One of these studies (McClanahan) interviewed 1,142 female detainees at the Cook County Department of Corrections found that childhood sexual victimization nearly doubled the odds of entry into prostitution throughout the lives of women. The other (McIntyre) noted that 82% of the sample had been “sexually violated” prior to their involvement in the sex trade, while three-quarters had a history of physical abuse. 

Many researchers have interviewed prostitutes who freely talk about the fact that they feel empowered selling sex to men because they feel like they are turning the table on them. They feel that they are now the ones in power. Of course, the sad truth is that they are no more in power than they were when they were being sexually molested. Please note: these studies primarily studied and interviewed prostitutes in the United States, Canada and Europe. Those that studied prostitution in third world countries such as in Asia and Africa found that other factors, such as poverty, were primary motivators for prostitution.

In addition to becoming involved with prostitution and stripping, former victims of CSA or sexual assault in adolescence or adulthood get involved with other activities, such as BDSM in an attempt to gain power and control. Ellen always took the passive role in her sexual reenactments but others take the aggressive or active role. This was the case with my client Tanya.

“I got involved with BDSM because it gave me a chance to be the one in power. I got to call the shots—I had all the control and it felt great. I got so good at it that I actually became a dominitrix for a while. Men paid me to humiliate them and make them feel powerless—like how I felt when I was being sexually abused. For a long time, this felt really good. But that was before therapy, before I figured out what I was actually doing, before I processed my feelings about being abused. Once I did that it turned my stomach to treat men the way I had been treated. It took all the pleasure out of it for me. I began to see them as helpless victims like I had been because who knows what had happened to them, you know? They were pathetic really and I no longer wanted to participate in their need to be punished.”

Another common way that former victims attempt to take back power and control is by becoming abusive themselves. By becoming an abuser, former victims can play the role of the more powerful person in the relationship in an attempt to overcome the powerlessness they felt as a child. My client Jake is a good example of this. This is what he shared with me when we first started working together.

“I guess the average guy can watch porn and not get triggered like I do. But what happens to me is I start feeling agitated. I feel like a caged animal—trapped in my own home, in my own skin. I immediately find some excuse to tell my wife I have to go out. Then I just drive. I drive until I see an opportunity. I might see a woman walking alone on a road, or I might see a Strip Club or bar that looks interesting. My goal is to have access to a woman, any woman, as quickly as I can. It doesn’t matter how old she is or what she looks like. She just needs to be available.

“I find a way to get the woman alone and then I try to convince her to have sex with me. I’m like a hungry animal; I have to satisfy my hunger. If the woman doesn’t cooperate, I become more and more aggressive. I do whatever I have to do to get her to give in to me—I lie, I manipulate, whatever I have to do. Sometimes I just need to coerce her to go with me to a secluded place. But if she ends up fighting me off, I get physical. I slap her, punch her—whatever I need to do to make her stop resisting.”

As Jake and I continued to work together we discovered the reason pornography was a trigger for him. When he was 12 years old, he was sexually abused by a neighbor who used pornography as part of his grooming process. The neighbor had groomed Jake by playing video games with him, providing him with sodas and later on alcohol, and by showing him pornographic films. Most of the films were about gay sex and afterwards he would molest Jake.

We then needed to understand the connection between his sexual abuse and his aggressive behavior toward women. Jake was finally able to make the connections we were looking for—the explanation for his abusive behavior after watching pornography. As it turned out, Jake felt compelled to watch pornography, even though he didn’t like how it made him feel. The reason he felt compelled to go searching for a woman after watching porn was that he unconsciously needed to prove to himself that he wasn’t gay. Another motivation: he needed to assert the power and control he had lost to the molester. And the rage he felt toward the women he forced to have sex with him was actually the rage he felt toward his perpetrator—the neighbor man.

A Reaction to Being Triggered   
Often a reenactment is caused by being triggered. If you noticed, Jake mentioned being triggered by the pornography he felt compelled to watch. The most common triggers for those who experienced child sexual abuse are:

  • Sounds, smells or tastes that remind you of the abuser or the environment where the abuse took place

  • The smell of alcohol, someone being drunk

  • Being in the dark

  • Someone reminding you of your abuser

  • Someone coming too close to you physically

  • Someone wanting to be emotionally close to you before you are ready

  • Being alone with someone

  • Being alone with a stranger in a small room

  • Being around pornography or someone who is watching pornography

  • Family get-togethers (especially for those who were abused by a family member)

  • Being touched

  • Someone flirting with you or making sexual comments

  • Being seduced

  • Being manipulated (if you do this, I’ll do that)

  • Being pressured (Oh come on, I know you’ll like it if you just try)

  • Secrets/clandestine activities

  • Feelings of betrayal

  • Lies and cover-ups

  • Blackmail, threats

  • Being “bought”

  • Cameras and video cameras  

An Attempt to Understand What Happened

Ongoing reenactments often indicate that a survivor is emotionally stuck. Some are attempting to work through an aspect of the trauma by repeating it with another person hoping that this time the result will be different. Others refuse to believe that someone they loved and/or respected could harm them in such a selfish way. Still others blame themselves for the abuse or have identified with the aggressor, and cannot admit to themselves what really happened. In this case, their reenactments are often unconscious ways to try to understand what happened to them, or their unconscious trying to force them out of denial. This was the situation with my client Monica who explained her situation this way:  

“I love my fiancé very much but whenever I am at an event or party without him, I almost always get into trouble. If a man comes on to me, I just can’t seem to push him away, especially if he comes on strong. I mean, I want to get away from him, but it is like my feet are in cement. I’m ashamed to say that I let these men touch me in places they should never have access to. Even worse, on several occasions I have let men pull me into a bathroom to have sex with me. I even have haunting memories of being slammed against a wall in a dark hallway. I’m so ashamed of my behavior. I just don’t understand myself.”

I explained to Monica that it is very common for survivors of sexual abuse or sexual assault to respond in the way she does when men approach them. There is a trauma response called “freezing” in which a person cannot defend themselves or even move when they are being attacked. Many describe it as a feeling like their feet are in cement. This explanation opened the door to Monica talking about the fact that she was attacked by a much older boy after choir practice at church when she was 13 years old.

“He started talking to me after choir. At first, I was flattered to have a boy so much older than me take interest in me. But then he tried to kiss me several times and I pulled away and told him to stop. No matter how often I pushed him away he just kept trying. I ran away and tried to avoid him from that time on.

“I thought I’d dealt with the problem, but I guess it made him angry that I pushed him away because one evening he waited for me and pulled me into an empty room and raped me. I tried to call out but there was no one around to save me. I’ve blocked out the details, but it was a horrible experience for me.”

“Did you tell anyone about it?” I asked.

“No, I was too embarrassed. I knew I shouldn’t have been talking to him in the first place. My mother has always warned me about talking to strangers, but I was flattered that an older boy took an interest in me, and I ignored her warning. I thought she’d get mad at me for being so careless. And I didn’t think anyone would believe me. After all, why would a boy so much older than me, a good-looking boy for that matter, bother with such a young and unattractive girl like me?”

As you can probably imagine, there was a lot going on with Monica and it explained why she was acting the way she did with men who approached her. She was so traumatized by the rape that she froze when men came onto her. She was unconsciously reenacting the trauma of being raped. Monica needed to acknowledge and process the feelings she had experienced when she was raped at 13, feelings she had tried to push away and forget. By doing so, and by realizing that the rape was not her fault, she was able to stop her reenactments entirely.

Passive and Active Reenactments

I’ve divided sexual reenactments into two major categories: passive and active (or aggressive). While those involved in reenactments are typically unaware of what they are doing, those who are involved with passive reenactments (men as well as women) are particularly unconscious when it comes to realizing they are reenacting previous trauma. They go about their lives, putting themselves in risky, if not dangerous situations, completely oblivious to their motive—replaying the trauma of child sexual abuse hoping for a different outcome.

Passive Reenactments

Passive behavior is continuing to view sex from a victim’s perspective and therefore can become a reenactment of the abuse. Behaving in any of these ways causes clients to feel ashamed and to continue to lose respect for themselves. Even more troubling, behaving in these passive ways is often re-traumatizing.

Examples of passive reenactments can include:  

  • Not being able to say no to someone who comes on to you or to getting involved with sexual activities that you are not interested in or are even repulsed by.

  • Allowing someone to pressure you into sex or demand sex of you.

  • Being involved with domineering/abusive partners.

  • Being involved with shame-inducing behaviors—sexual activities that cause you to feel deep shame during or after sex. Examples: someone humiliating you sexually or saying derogatory things to you during or after sex.

  • Practicing risky behaviors such as drinking too much or taking drugs at bars or parties, especially when out alone or where you don’t know anyone. This includes not watching your drink or leaving your drink to go to the restroom and not insisting that a man where a condom.  

Aggressive Reenactments

Those who identified with the aggressor or hid their shame behind a wall of arrogance or bravado often recreate the abuse by being aggressive sexually. This can include:

  • Being sexually inappropriate (standing too close to a stranger, touching a stranger in an intimate way [hand on their leg, hip, back, behind]).

  • Being sexually coercive or demanding.

  • Humiliating and degrading your sexual partners.

  • Being emotionally, physically or sexually abusive toward your partner.    

Identifying Shame-Inducing Sexual Compulsions

Shame is by far the most damaging aspect of CSA. Former victims carry a great deal of shame, causing them to have low self-esteem, self-hatred, a tendency to blame themselves when things go wrong, and a general feeling of being “less than” other people. If things weren’t bad enough for former victims, some find themselves locked into compulsive sexual behavior that can perpetuate feelings of helplessness, a sense of being bad, or out of control, resulting in further shaming. These sexual compulsions happen outside of conscious awareness and are often characterized by dissociation of thoughts, emotions and sensations related to the traumatic event.

The list below are some of the most common shame-inducing sexual compulsions––

sexual activities that can cause you to repeatedly reenact the pain, fear, or humiliation of the sexual trauma you suffered (either as the one in power or as the victim).    

  • Engaging in humiliating sexual practices (sadomasochism, sex with animals)

  • Combining sex with physical or emotional abuse or pain

  • Frequent use of abusive sexual fantasies (either seeing oneself as the abuser or the abused)

  • Engaging in promiscuous sex (many sexual relationships at the same time or in a row)

  • Charging money for sex

  • Having anonymous sex (in rest rooms, adult bookstores, telephone sex services)

  • Acting out sexually in ways that are harmful to others (forcing someone to have sex)

  • Acting out in ways that are harmful to yourself (allow yourself to be humiliated during sex)

  • Manipulating others into having sex with you

  • Demanding sex from others

  • Using rape or other types of fantasies to gain sexual arousal or increase sexual arousal

  • Committing sexual offenses (voyeurism, exhibitionism, molestation, sex with minors, incest, rape)

  • Feeling addictively drawn to certain unhealthy sexual behaviors (sadomasochism)

  • Continually using sexual slurs or degrading sexual comments to humiliate your partner or allowing your partner to do this to you

  • Engaging in secretive or illicit sexual activities

  • Relying on abusive pornography in order to become aroused   

Other sexual compulsions can be less obvious reenactments of the trauma of child sexual abuse and are more likely to be ways to cope with stress or self-punishing behaviors such as:

  • Engaging in compulsive masturbation

  • Engaging in risky sexual behavior (not using protection against disease or pregnancy)

  • Being dishonest about sexual relationships (has more than one partner but professing to be monogamous)

  • Engaging in sexual behavior that has caused problems in your primary relationship, at work, or with your health   

Eliminating Shame Inducing Behavior

If a client wishes to reduce or eliminate the amount of shame they feel they typically need to remove the above behaviors from their sexual repertoire. The same holds true if they wish to eliminate the likelihood that they will become involved in sexual reenactments. The most extreme, and therefore the most shaming of these behaviors include: talking to or treating your partner in degrading ways or asking to be talked to or treated in these ways; demanding sex or forcing someone to have sex; watching violent pornography; engaging in sadomasochism; and engaging in other dangerous sexual activities. These activities are all examples of extreme shame-inducing behaviors and are often reenactments of the abuse. Therefore, it is vitally important that your clients make a special effort to first identify and then to eliminate these particular behaviors from their sexual repertoire.

I’ve outlined some of the specific changes your clients can begin to make in order to eliminate these shame-producing behaviors and attitudes that may have dictated their sexual life.

Remedies for Passive Reenactors



Learning to Say No

While it may seem obvious that saying no is important and necessary, the truth is that many women and men don’t know they have the right to do so. It is also true that even more people don’t know how to say it. Practicing how to say “No!” teaches someone how to literally say “No!” in a strong, assertive manner—but perhaps even more important, it will give them permission to say it, not just with their words, but also with their actions and attitude. It will show them that they don’t have to just put up with unwanted sexual remarks or touches, and that by keeping silent, they may be giving people permission to go further than they should. It will help them to understand, on a deep emotional level, that they have a right to expect that their body is off-limits to anyone they don’t want touching them. The following exercise will help your clients become stronger in their resolve to stop allowing people to pressure them sexually.

Exercise #1 Saying No!

  • Think of a fairly current situation in which someone recently disrespected, invaded or abused your body.

  • Imagine that you are saying “No!” to this person.

  • Now say it out loud. Say “No!” as many times as you feel like it. Notice how good it feels to say it.

  • If you’d like, in addition to saying “No!” add any other words you feel like saying. For example, “No! You can’t do those things to me.” “No! I don’t want you to touch me like that!”  

Practicing saying “No!” will help your clients gain the needed courage to say it when they need to—whenever someone is trying to coerce them into sex when they don’t want it.

Know what is Healthy for You and What is Off-limits

This step is an especially crucial one. In many cases this goes beyond sexual “preferences” to sexual needs. For example, if the person who molested your client fondled their breasts as a part of the molestation, they may have an aversion to having their breasts touched. This is a common scenario and is completely understandable. On the other hand, if the perpetrator did everything else but touch their breasts, that may be a “safe zone” for them, a place on their body where they are not re-traumatized and from which they can actually derive some pleasure. If the perpetrator did not penetrate their vagina with his finger, his penis, or another object, having vaginal intercourse may be their “safe zone,” and may be quite pleasurable. A fairly common scenario is for former victims of CSA to be able to enjoy having their partner touch those parts of their body that were not touched by the abuser, as well as enjoying engaging in sexual activities that the abuser did not impose on them.

Exercise: What’s Off-Limits

  • Make a list of the parts of your body you find uncomfortable to have touched. Don’t worry if you end up listing many parts of your body. This is common for former victims and is a reminder of just how traumatic the abuse was.

  • Try to find the reason as to why someone touching a particular part of your body is uncomfortable for you. It probably is due to the fact that this part of your body was involved in the sexual abuse in some way.

  • Now make a list of sexual activities that are uncomfortable, shaming, or triggering for you. Try to be as honest as you can, even if it means listing activities you believe you “should” like to do or have been doing.

  • Write about the reasons why you think these sexual activities are uncomfortable, shaming or triggering for you. The more connections you can make the more in charge of your sexuality you will become.

  • Finally, list the parts of other people’s body that you find uncomfortable to touch.

  • Think of the possible reasons why these body parts are uncomfortable for you to touch.

  • Now complete the following sentences:

Some parts of my body are just off-limits. These are: ___________________________________________________________________________________________________________

I am triggered by (have a post-traumatic response to) certain sex acts. These are: ___________________________________________________________________.

I am not comfortable looking at, touching, or feeling some parts of another person’s body. These are: _________________________________________________________________________.

Feel free to share these exercises with your clients but please cite the source (Put Your Past in the Past).

Remedies for Aggressive Reenactors

In the same way that many former victims reenact the abuse they experienced by being passive, many react to past abuse by being aggressive. As we have discussed, these people attempt to avoid further shaming by building a wall of protection to insulate themselves from the criticism of others. These same people often become bullies—attacking others before they have a chance to be attacked. But behind that aggression, behind that need to dominate or humiliate others, is a little child who is still shaking in his boots. Pretending to be tough and strong isn’t really solving the problem, and shaming and humiliating others before they have a chance to do it doesn’t help either. What will help is for your client to take off their mask, tear down that wall, and face the truth. They are just as vulnerable, just as hurt as any other victim of child abuse and they need to address their pain, humiliation, and fear instead of hiding it from themselves. Suggest they start by doing the following:

  • Instead of demanding sex or compulsively masturbating, or watching pornography, ask yourself if sex is really what you need? Young children who were sexually abused often discover, perhaps for the first time, that their sexual organs can provide good feelings. This can be the start of compulsive masturbation or a sexual addiction. The child, and later the adult, grows to rely on sexual pleasure and sexual release in order to cope with feelings of shame, anxiety, fear, and anger. When you begin to obsess about sex it may be a signal that you are feeling shame or that you are feeling anxious, afraid, or angry. Or you may have been triggered. In addition, you may use sex as a way of avoiding your feelings and staying dissociated. For many former victims, sex becomes one of the only ways they can feel worthy, or they can interact with another person. In other words, your client may be having sex to fill needs that are not necessarily sexual, such as needs for physical contact, intimacy, and self-worth. They may be seeking sex because they need to be held. Many former victims don’t feel loved unless they are engaging in sex with someone.

  • Ask yourself what sexual activity or sexual compulsion does for you. For example: What needs are you trying to fill when you have sex? Is sex the only way you can connect with other people? Is it the only way you think you can be loved? What painful emotions does the compulsion help you avoid? One of my clients answered the question in this way: Having a lot of sex makes me feel powerful. It keeps me from feeling how helpless and powerless I felt when I was being abused by my father.

  • If you discover that you are using sex, or fantasies of sex, to cope with shame, anxiety, fear or anger, find other, healthier ways of coping. This is also where self-soothing strategies come in. Instead of using sex or sexual fantasies to soothe yourself, find soothing strategies that work for you (taking a warm bath, gently touching your arm and saying something like, “You’re okay,” or “You’re safe now”).

  • Learn what your triggers are—what emotions or circumstances catapult you back in the past to memories of the abuse. If you haven’t made a trigger list, do so now.

  • Check to see if you have been triggered by shame. Shame is an especially powerful yet common trigger. For example, if you have been triggered by shame (your partner complains about the fact that you don’t make more money) offer yourself some self-compassion. Compassion is the antidote to shame so tell yourself something like, “It is understandable that I would feel shame about not making more money. But I am doing the best I can under the circumstances. I don’t feel good enough about myself to go out and try to find a better paying job but eventually I will.”

  • If you tend to be sexually controlling or demanding, practice taking a more passive-receptive role. At first this will likely feel uncomfortable or even scary. You took on an aggressive stance in order to avoid feeling small or vulnerable. But if you can practice being more passive a little at a time (i.e., adjusting so that you are on the bottom and your partner is on top) you will likely discover that it actually feels good to relax and let your partner, take over.

  • Allow yourself to be more vulnerable with your sexual partners. If a partner has opened up to you and shared information about their childhood, see if you can do the same. You don’t have to tell the person that you were sexually abused, but test out how it feels to share other information about your childhood that you don’t normally share with others. Opening up and becoming vulnerable will feel risky at first but if you choose wisely who you reveal yourself to, you will likely discover that it feels good to be more open.

  • Avoid exposure to things that reinforce or replicate the sexual abuse mindset. This includes television programs, movies, books, magazines, websites, and other influences that portray sex as manipulation, coercion, domination, or violence.

  • Avoid pornography or work toward weaning yourself off of pornography if you use it regularly or feel you might be addicted. For former victims of CSA watching pornography can be especially problematic because you are reenacting an abusive dynamic that disengages you from yourself, and opportunities for respectful sexual relationships. Pornography has aspects of sexual abuse such as secrecy, shame, and dominance—all tied up with sexual arousal. Pornography is especially harmful to sexual healing because it is often a depiction of sex as one person dominating another (usually a male dominating a female) which is a reenactment of CSA. Specific problems caused by watching pornography include:

    • Those who were sexually abused are often inundated with feelings of shame and try to distract themselves from these feelings by watching porn. But ironically, after viewing pornography and masturbating to it, it is common for former victims to feel shame, disgust and failure—the very feelings they have been trying to get relief from in the first place.

    • Former victims tend to keep their pornography watching a secret from their partners. This can mirror the way sexual abuse was kept a secret, and in that sense can be a reenactment. When their partner finds out their sense of betrayal can be overwhelming and can cause as much harm to the relationship as pornography itself. More than one-quarter of women viewed pornography watching as a kind of affair. (10)

    • Viewing pornography is, generally speaking, not about connection, intimacy, and affection. Instead, there is a blurring of boundaries around acceptable sexual behaviors, especially where there are overtly humiliating or degrading practices. Researchers have found that over 80% of pornography includes acts of physical aggression towards women, while almost 50% includes verbal aggression. Only 10% of scenes contained positive caring behaviors such as kissing, embracing or laughter.

    • Research also shows that viewing pornography can influence the viewer’s sexual interests and practices. A 2011 study found that people who watched violent pornographic material were more likely to report that they had done something sexually violent or aggressive. Another study found that men who watch violent pornography or are frequent viewers of pornography, are more likely to say they would rape a woman if they could get away with it.   

  • Use new language when referring to sex. The way a person talks about sex influences how he or she thinks about it. Avoid slang terms such as screwing, banging, getting a piece, etc. Instead, use terms such as making love, being physically intimate. Stop using words for sex parts such as prick, dick, boobs, tits, cunt, and asshole. Instead, use anatomically correct and accurate terms such as penis, breasts, vagina, and anus.

  • Learn more about healthy sex. Read books and articles that can help you educate yourself more about healthy sex. Attend classes, lectures, or workshops at which healthy models for sex are being presented.

  • Tell someone about the abuse. The most important benefit of disclosing is that you will be allowing yourself to be vulnerable and to admitting how much you were hurt. This will help you lower your defenses and not always have to be the one in charge.

  • Enter psychotherapy or join a survivor’s group. This can be especially difficult for males. Research has found that male survivors are less likely to report or discuss their trauma, and more likely to externalize their responses to CSA by engaging in compulsive sexual behavior.   

***

It is vitally important that clients stop blaming themselves for the ways they have attempted to cope with the sexual abuse they experienced. I’ve never met a sexual abuse victim who didn’t have sexual issues—whether it is the two extremes of avoiding sex, or being sexually promiscuous; having feelings of fear or repulsion about certain sexual behaviors, or parts of the body; or inappropriate or even dangerous sexual fantasies or compulsions. But this doesn’t mean it isn’t possible to confront and heal these unhealthy ideas and practices.

References

(1) Natalie, Tapia. (2014). Survivors of child sex abuse and predictors of adult re-victimization in the United States. International Journal of Clinical Justice Sciences. 9(1),64-73.

(2) Filipas, H., & Ullman, S. (2006). Child sexual abuse, coping responses, self-blame, post-traumatic stress, and adult sexual revictimization. Journal of Interpersonal Violence, 21(5), 652-672.

(3) Noll, J. G. (2003). Re-victimization and self-harm in females who experienced childhood sexual abuse: Results from a prospective s. Journal of Interpersonal Violence 12(18), 1452-71.

(4) Oshri, A, et. Al. (2012). Childhood maltreatment histories, alcohol and other drug use symptoms, and sexual risk in a treatment sample of adolescents. American Journal of Public Health. 102(82), S250-S257.

(5). Classen, C. C., et.al. (2005). Sexual re-victimization: A review of empirical literature. Treating Violence and Abuse.4(6), 103-129.

(6) Hanson, R. K., & Slater, S. (1988). Sexual victimization in the history of child sexual abusers: A review. Annals of Sex Research, 1:485-499.

(7) Baril, K. (n.d.). Sexual abuse in the childhood of perpetrators: INSPQ. Institut national de santé publique du Québec. https://www.inspq.qc.ca/en/sexual-assault/fact-sheets/sexual-abuse-childhood-perpetrators 

(8) McClanahan, S., etal. (1999). Pathways into prostitution among female jail detainees and the implications for mental health services. Psychiatric Services, December, 50 (12), 1606-1613.

(9) McIntyre, J. K., & Spatz Widom, C. (2011). Childhood victimization and crime victimization. Journal of Interpersonal Violence, 26(4), 640–663.

(10) Lumby, C., Albury, K., & McKee, A. (2019, February 12). Problematic use of pornography – living well. Living Well – A resource for men who have been sexually abused or sexually assaulted, for partners, family and friends and for professionals. https://livingwell.org.au/managing-difficulties/problematic-use-pornography/

Advanced Harm Reduction: Managing Intoxicated Clients

Posted on by Psychotherapy.net Team

First there was abstinence, then it was abstinence versus harm reduction. Now, “it appears that intoxication management is becoming a necessary skill for therapists”. With the ubiquity of alcohol use and its presence as an increasingly high-end activity, the growing legalization of marijuana, mini-dosing, psychedelic therapy and the ever-growing use of psychiatric drugs at younger ages … what’s a therapist to do?

The Goal of Abstinence

Abstinence has traditionally been the goal of treatment for substance use disorders. And while many therapists, particularly those with 12-step backgrounds, continue to tout abstinence, several factors have challenged its once hallowed position at the top of the treatment goal hierarchy.

Abstinence supporters and opponents alternately argue on the following grounds (supporters in plain type, opponents in italics):

  • Abstinence provides a clear and unambiguous target
  • People will refuse treatment altogether if they must quit entirely
  • In order to participate constructively in therapy, the mind and body must be clear of intoxicants
  • While living in a monastery or being in rehab encourages abstaining, living in the real world requires some substance exposure and use
  • Some drugs create such an intense rush that users must dissociate themselves in order to recalibrate their pleasure responses
  • Those on antidepressants, as well as medications for bipolar and other prescribed medications who encounter problems with using the drug, on the other hand, court lethargy and possibly intolerable dysphoria by quitting
  • While avoiding one substance may be called for, there may be little cross tolerance or susceptibility to problems with use of another
  • Giving in to the urge to use one drug reduces overall willpower strength, according to Roy Baumeister and John Tierney’s best seller on the topic

A Self-Labeled Alcoholic

Joyce drank heavily as a teenager, quitting in her early 20s. She attended AA, remade herself, and moved far away from her home state. Over the years, she smoked pot, and took medication as indicated for pain or sleep or anxiety, but with a wary eye on her penchant for addiction. She succeeded in not using anything excessively or addictively.

Along the way, Joyce developed severe depression, which antidepressants relieved. Eventually, she worried that she had become dependent on the medication, which caused her to stop. But, “when Joyce renewed use of the drug, she had a frightening suicide-ideation reaction”. She has been terrified of that medical category of drug since then. Joyce is prescribed and occasionally takes anti-anxiety medication, which she uses sparingly due to her fear of addiction. She has found opiates very helpful for her moods but understands that they should not be used that way and mindfully avoids traveling too far down that road when prescribed opioids for pain. She continues to consider reintroducing a depression medication into her life if she can get past her fear of them.

Although some cannabis advocates would say that she is using marijuana therapeutically, Joyce views her use of that drug as strictly recreational and restricts her use to evenings. Using the drug in this way doesn’t interfere with her work or other life functions, and she feels she can take the drug or leave it on any given night depending on her mood and what she’s doing. Keep in mind that Joyce remains completely “sober” with regards to alcohol, per her AA experience, though she occasionally uses Nyquil or cooks with alcohol. Many people in her current social group drink moderately, so that Joyce understands such drinking is readily possible.

Drug Use by the Formerly Addicted

An acknowledged “recovering” alcoholic, Joyce is far from being sober by strict 12-step standards. According to her former AA cohort, Joyce is living in dangerous territory. She uses mood-altering substances for fun, and she continues to take a variety of psychoactive medications. She also no longer attends meetings. Yet she is solid in her conviction that she is now a sober individual, and proud of it.

Joyce is in many ways a prototype of the modern American polydrug user. Her life calls into question the meaning of the terms abstinence, sobriety, and recovery. Of course, even the most hard-core abstinence proponents often don’t include cigarettes and coffee in their sobriety calculus, although both are addictive and can have serious negative health consequences. “There is still heated debate among 12-step adherents about taking medications”—their allegiance to abstinence precepts ranges from scorning all medication including not even taking an aspirin under any circumstances, to accepting prescribed medications, to believing use of anything that isn’t your drug of choice is okay (like Joyce’s easy use of cannabis). And this is before even considering the modern harm-reduction movement’s scope, including moderate use of a formerly abused substance, substituting a safer version of an addictive drug like taking suboxone or methadone in place of heroin and even continuing addictive or binge use under safe conditions (e.g., using heroin with clean needles or in a supervised consumption site).

Here are what we believe to be the underlying, fundamental guidelines for discussing continued substance use with people who have been diagnosed with or who themselves believe, as Joyce does regarding alcohol, that they have a substance use disorder:

  • Be open minded and willing to consider all substance use options: abstinence, substitution or replacement with other substances, moderation, safer use, occasional or regulated addictive or intense use.
  • Remain mindful of—and review—experienced outcomes with clients (this opposes the idea of “denial,” taken to mean that clients cannot accurately report their substance-use experiences).
  • Measure the success of treatments against actual life functions—work, family and friends, and especially subjective client feelings.
  • Avoid labeling the client or his or her substance use pejoratively as addictive, bad, or equally as harmful in all forms or methods of use.
  • Consider first and foremost client values and preferences by using motivational techniques in use decision-making.
  • Change is part of the process—the person, their situation, and the interchange between them are always in flux. There is no permanent solution.
We are in a sense in the new frontier of almost infinitely available substance use, considering that illicit opiates and other drugs can be ordered over the “Dark Web.” It does no good to regret or bemoan this reality. “In a sense, we are at the final societal stage of what therapists should regard as the goal in all therapy”—realizing the clients’ agency and freedom of choice in devising their best selves.

Rethinking Non-Problematic Substance Use

The 12 steps can be seen as one expression of American temperance attitudes that consider all forms of intoxicant use and intoxication to be bad or wrong—or, in modern terms, problematic, disordered, or addictive.

Consider Mary, who LOVES to smoke pot. She smokes it all day long, whenever she can, and she always strives to have a supply available. She also drinks, not heavily, but she likes to go out and get a little fuzzy and sparkly with alcohol once or twice a week. Do you think Mary has a substance problem? On the face of it, she uses substances regularly, heavily, and possibly dependently or addictively in the case of marijuana.

Mary owns and manages a local restaurant where she is beloved by workers and customers alike. She is responsible for its financial success as much as the hands-on and the public-facing part of the business. Mary also organizes large rallies and fundraisers for community causes. She is a good citizen. She is strong-willed and plain-spoken. She has a positive marriage. And she is happy with her lifestyle as it is, thank you very much.

“Mary knows something about addiction”. She used to do cocaine heavily, with terrible consequences for her and her husband’s lives. But that was many years in the past. Today, she seems dependent on pot, while her drinking is generally moderate and she doesn’t overdo her use of any other substance, including occasionally prescribed medications. Yet she rejects and is alarmed by destructive substance use, as occurred in her own life with cocaine.

Mary, like Joyce, expresses several contemporary trends in substance use attitudes and practices. She doesn’t accept standard substance use disorder definitions and recommended usage levels. She accepts, even welcomes, mood modification—a.k.a. intoxication when substances aren’t prescribed for therapeutic purposes. And she doesn’t feel limited by her intensely negative, i.e. addictive, former use of cocaine.

Consider Greg. He was a heroin addict in the late ‘60s, long before so much awareness and availability of opioids use had developed. He shot up, lived on the streets, the whole nine yards of addiction. He was lucky because he had a strong family (parents and siblings), and after many years of addiction, he went to a TC (therapeutic community) and finally quit heroin.

Those communities, at that time, allowed clients to reintroduce moderate drinking after a period of abstinence. That idea worked for many TC adherents, although Greg’s idea of moderation seriously exceeded recommended amounts for safe use. Greg drank to intoxication, specifically, two nights a week, although he never touched any other drug. He was positive that if he ever smoked a joint that he would go right back to heroin, and cocaine was just not his thing. But Greg put alcohol in a completely different category.

As he aged, Greg continued to drink two nights a week, but much less heavily. In many ways he followed a typical pathway of natural recovery with alcohol, even as he was a fully recovered heroin addict. And, we should also note, Greg identified personal emotional issues, made substantial changes to his life and created a life he could better live with than when he had been addicted to heroin.

Regarding Greg’s dual pathways to sobriety—one with opioids, one with alcohol—”do we really think that someone who has, for instance, kicked a 10-year heroin habit has relapsed if they have a beer on a hot summer day?” Greg didn’t fit this mold. He was a heavy and, for a time, potentially harmful drinker. But what if a formerly addicted person gets drunk at a class reunion every year? Should we perform an intervention? Or are these simply life events, rather than cases requiring a clinical consult?

We as Americans think use of some substances is more acceptable than others: antidepressants are consumed in enormous amounts, along with Adderall, sedatives, and anti-anxiety drugs (benzodiazepines) and other psychiatric medications. What about coffee, colas, and energy drinks? Now marijuana, depending on your residence, is used both recreationally and as medicine.

As for painkillers, we love them and we hate them. Americans have a strong urge to eradicate pain. It is normal to seek relief from pain. Yet we now have become overwhelmed by our quest for pain relief, including, seemingly, relief from the mental and emotional distress of daily life. We need to look seriously at what this need for escape says about society, particularly in areas characterized by little education, high unemployment, and so-called crises of despair.

Empowering People to Find Purpose

Allowing people to feel safe in openly discussing their lives with their counselors and providers, to convey what it is they think they are doing rather than what their counselor thinks they are or should be doing, increases trust and allows for a collaborative therapeutic relationship. This open process must include acknowledgment of and handling intoxicant use.

Such a therapeutic alliance encourages the client’s sense of agency. “A path of empowerment by clients’ self-identification of their individual values and goals is the ultimate objective” in this conception of therapy and helping. It is not a therapist’s job to identify how someone should live, but rather to explore and to help illuminate what is their best way in life, their unique purpose, with and without regard to their substance use profile.

Perhaps we should celebrate the availability of a modern cornucopia of substances for driving this point home.  

Cathy Cole on Motivational Interviewing

Posted on by rezendevknowfully.com

Talking About Change

Victor Yalom: I think a good place to start would be to define and describe exactly what Motivational Interviewing is.
Cathy Cole: Motivational Interviewing is a counseling approach that has a very specific goal, which is to allow the client to explore ambivalence around making a change in a particular target behavior. In Motivational Interviewing, the counselor is working to have clients talk about their own particular reasons for change and, more importantly, talk about how they might strengthen that motivation for change and what way making that change will work for them. It’s a way for the counselor to guide a conversation toward the client’s goals, making the choices that are going to work for a particular person.
VY: I know the founder of this, Bill Miller, started in the field of addictions, where, at least for many counselors, there is a very different model of change, which is that the counselor needs to somehow break through the client’s resistance or denial about their drinking problem. In that context, MI has a very different philosophy.
CC: We really wouldn’t view that as resistance. In Motivational Interviewing, we’re listening very closely to what the client says and, more importantly, how the client is saying it. We’re listening for two kinds of language with clients: either sustain talk or change talk. What we might have considered resistance or what had been called denial in the past would actually just be consider sustain talk—reasons not to do something different, like reasons why stopping drinking would not be important, or reasons why, even if it’s considered important, the client doesn’t think they’re capable, or reasons why the client says, “I’m not ready to do this.”
VY: So in traditional alcohol counseling, for example, reasons why they don’t want to change are seen as resistance or denial.
CC: That was considered denial in the past. And it was viewed as the client not having paid enough attention yet to what the professional said they need to take a look at.
VY: So the professional is really the expert.
CC: That’s right. And in Motivational Interviewing, the client is considered the expert.
VY: Miller gives a lot of credit to Carl Rogers’s person-centered therapy in that regard.
CC: He does, and the basic conversational methods that are used in Motivational Interviewing came out of some of the client-centered work, particularly the use of reflective listening. When Bill Miller began to discuss this, he talked about the client being the expert. The clients are the ones who know themselves better than anyone else. The clients have strengths and capabilities, and clients have the ability to decide if making a change is important to them and why, and what would work best for them in terms of going about that change.

This is quite different from the traditional model of, “Here’s your problem. Here’s what you need to do. And if you don’t do it, that’s your problem, too.”

Of course, the counselor has an important role with this, because sometimes clients want to make change but they don’t really know how. So if, after fully exploring clients’ ideas about making change and what would work for them, the client still feels lost, we’re able to come in and provide some ideas for them to consider—things that we know have been helpful to other people or specific ways of approaching, say, stopping drinking. But ultimately, the clients are the ones who decide what they’re going to do. So this was quite different from the traditional model of, “Here’s your problem. Here’s what you need to do. And if you don’t do it, that’s your problem, too.”

VY: That’s the underlying philosophy of it, and then there are a lot of specific techniques. It’s very strategic, from my understanding. You mentioned one idea of sustain talk, and that is the clients telling you why they want to sustain or continue what they’ve currently been doing.
CC: Right. They’re telling you why they’re not going to do something different.
VY: When you’re hearing sustain talk, your goal is not to try to argue them out of it. You’re not trying to show them that they have some irrational thinking or beliefs. What’s your goal in listening to sustain talk?
CC: To me, there are two goals in listening to sustain talk. The first goal is for me to listen so that I really understand the client’s perspective and of why they are where they are with this particular behavior, and what might be interfering with them considering making a change. So I want to first really work on understanding that. And the way that I’m going to convey that I’m understanding that is by the use of reflection. The next thing that I want to do is to use various kinds of open questions to help the client completely explore the sustain talk, again, toward the goal of the client being able to make an informed choice about whether or not they’re going to change.
VY: And the other type of talk, to call it that, is change talk. That’s a really interesting idea, I think, especially for therapists. What is change talk?
CC: Change talk is when the client begins to shift and say that perhaps making change is important, or perhaps they are able to do it, or perhaps they are ready to do it. They begin to shift away from the reasons not to and they move into the direction of the reasons to make change, or the capability of making change, or that readiness to make change. And that change talk can be very subtle; it can be something that we have to really listen for. It may not be the dramatic, “Yes, I have changed my mind. Now I am definitely going to start losing weight or stop drinking or making a change in my drinking.” It could be as subtle as, “Maybe I should start thinking about that.” And the moment that that occurs, we want to then change what we’re doing in relation to that change talk.
VY: I know that Motivational Interviewing is used in a wide variety of settings, from addictions to healthcare, medicine, the criminal justice system. But just to keep things simple for now, let’s use the example of addictions, where it started. Can you give me an example of someone is struggling with drinking and give an example of sustain talk and change talk, and how you might listen for the change talk, and what you might do with it?
CC: The sustain talk might be something like, “My drinking is no worse than any of the other people I hang around with. In fact, sometimes I don’t think I drink as much as they do.” So that’s saying this is no big deal.A shift of that might be, “Well, when I think about it, I realize that some of the people I drink with actually do say ‘I’ve had enough’ and they quit. And I don’t always do that. Even if I feel like I’ve had enough, I just keep on drinking.” Many people might not hear that as change talk, but I hear that as change talk because the person is beginning to take a look at this and the drinking in a different way. I would really want to attend to that very carefully, and then help the client expand on that.

VY: How do you help them expand on it when you first hear that subtle shift?
CC: Continuing this example, my first response would be to do a reflection. I might say, “You’re beginning to pay attention to how your drinking pattern is not the same and realizing that there could be some pretty important differences.” I’m reinforcing the beginning of the client looking at this in a different way. By doing the reflection, that then provides the opportunity for the client to expand on what he’s beginning to think about.
VY: But you’re not jumping on it.
CC: No, I’m not jumping on it like, “Okay, so you really want to do something different,” because I’m just hearing the beginning of it. Again, MI is very client-centric, so I am helping the client move forward just a little bit, and I’m letting him now expand on this little bit of daylight that has started to show up here in terms of him thinking, “Maybe this is something I could look at in somewhat of a different way.” I want to help him move that along. But if I get too far ahead by saying, “Okay, so you realize that you have a problem,” the client will probably immediately push back to sustain talk because I will have gotten ahead of the client or really created some discord in the relationship at that point. So it’s very strategic in terms of how far ahead I’ll actually move.
VY: I know it’s a really important concept in Motivational Interviewing, for the therapist or counselor not to be the one arguing for change.
CC: Absolutely. The clients are always the ones that argue for change. We set the stage for them to be able to do that, should they want to, but they always present the argument for change.
VY: What is the rationale behind that?
CC: The rationale is if we have decided on our own that making a change is important, we’re far more likely to do it. And it’s also human nature that if someone else tells us that we have to make a change, even if we know we need to do that, we argue against it. We push back.
VY: So with this hypothetical client, say you reflect back the early change talk. How might it progress from there?
CC: Then the client says, “Yeah. I realize that if we go out drinking on the weekends, my other friends know that maybe they can drink a little bit more on a Saturday night, but when it comes to Sunday that they need to cut back and maybe not drink at all, or just have one drink. And they go to work on Mondays. I often don’t really slow it down. I continue to drink just as much on Sunday, sometimes maybe even a little more. And I sometimes don’t end up going to work. So I’m a little bit different than they are with my drinking.”To that, I might actually say a reflection back: “Your drinking takes on a life of its own. It actually gets ahead of you.”

VY: Okay, you summarize what they’re saying. You say you don’t want to get too far ahead of the client, but sometimes you might amplify their reflection?
CC: I’ll amplify that a little bit more. I took a little bit more of a step out this time, a little bit more of a risk, because the client actually started giving me more information. He started to have a different perspective. So I edged it out a little bit and really did a metaphor: “Your drinking has a life of its own, and sometimes it moves ahead of you.” I started to help the client really compare and contrast his drinking with other people’s drinking and just expanded, really, on what the client has said.
VY: It’s really a conversation between the two of you. The therapist does a lot of reflection and trusts that ultimately it’s the client’s decision whether they’re going to stop drinking, start exercising, manage their diabetes better, or whatever the behavior is. Does this tend to go on for a long period of time throughout a course of counseling? Is it very focused on a specific behavior?
CC: Motivational Interviewing the way that we’re using it is focused on a particular target behavior. It’s something that the client is talking about with a sense of, “I need to figure out how to deal with this.” Motivational Interviewing is actually considered a somewhat brief way of working with people in that the person is deciding whether they’re going to do something and then what they’re going to do.Let’s say the drinking from our earlier example is the target behavior. The client decides over the course of a couple interviews that this is a bigger deal in life than he had looked at before, so he’s saying, “Now I’m going to do something about this.” Now we’re getting a clear message of, “Yes, I want to move ahead.” So we begin to take a look at how capable the client feels of doing something about this and what it is he wants to do.

Let’s say I’m an outpatient therapist and doing a specific alcohol treatment is not necessarily my strong suit, but I have this client who comes in and that’s what the client wants to explore. It could be that in the course of that conversation, the client decides, “I’m going to do something about this. I’m going to go to a specific center or perhaps even an inpatient program that deals with alcohol problems.” Or let’s say that it’s a brief intervention to help the client get to the place of saying, “Yes. Now I’m going to do something about it,” and then he moves into planning how he’s going to do something about it. That might mean that the person moves away from me and that I’m not working with him any longer.

But let’s say that I am comfortable working with an alcohol problem. So now we have resolved that initial ambivalence. We’ve moved toward, “Yes, this is what we’re going to work on together.” At this point, we’re going to be working with whatever the client needs to take a look at: for instance, is he planning to try to moderate, or is he planning to try to stop altogether? If he’s going to stop altogether, what do we need to address with that? What might be barriers for him in continuing to maintain abstinence once he’s established it? So we’re not into the nuts and bolts of how he’s going to do it. I’m still not telling him what to do, but I’ve shifted away from that first part of Motivational Interviewing, which is just to resolve that ambivalence about doing it in the first place.

But let’s say that client is continuing along in therapy and with this change plan, and couple of months down the line, the client now says, “I don’t know. Maybe I don’t really need to continue to do this any longer.” So now we’re just going to explore that again. I’m always listening for where the client might become uncertain about continuing to work on this particular behavior. Then we’re going to come back and use Motivational Interviewing to work with that ambivalence.

Stages of Change: Importance, Ambivalence, Confidence

VY: Coinciding with this interview, we’ve just completed a series of Motivational Interviewing videos with you. The first one lays out the general principles, and then the next three address different stages in the change process. It’s an interesting way of thinking about the process of change in general. The first one deals with the idea of increasing importance. Can you just state briefly what is meant by that?
CC: When we talk about increasing importance, we are basically talking about the client’s buy-in around making change. The client has to decide, “Why is this an important issue for me in the first place? Why is it important for me to take a look at the role of drinking in my life? In what ways might it be creating problems for me? In what ways would taking a look at this and making some changes enhance, perhaps, parts of my life or what difference does it make for me to actually control my diabetes when I’m going to have it forever anyway? Why would I stop smoking? Why would that be important?” That’s the first thing when we’re talking about making a change. First, we have to believe that making the change is important, because if we don’t believe that it’s important to make a change, then we’re really not going to do anything.
VY: So first the client has to at least consider that it is important for them to change. And even when they consider it’s important, the idea that they might change is often counterbalanced by inertia or sustain talk—they still might be ambivalent about actually going ahead with it.
CC: Exactly. If we think about it, probably one of the most common questions that the majority of people deal with is, “Is it important that I eat in a certain way so that I maintain the health that I currently have? Is it important that I have a regular exercise routine?” And a lot of times, clients don’t actually realize that it is important for them to make a change.Let’s take an example of a client who has had a yearly physical with routine screenings, lab tests, things like that. The doctor points out that some of her lab values are off. Let’s say liver enzymes are off or cholesterol is high. The client has really not even considered that she needs to make any kind of a change, and now the doctor is saying, “These are indicators to me that you should take a look at these things in your life—that you should take a look at your diet, you should take a look at your drinking, you should take a look at the use of exercise to have an impact on these particular health issues that I have a concern about.”

VY: So this is all new information to the client. For the first time, she thinks, “Gee, maybe it’s important that I make some lifestyle changes.”
CC: Exactly. And other times clients have sought counseling about something that they think might be important, but they’re not sure yet. So they’ve come to sort that out for themselves. Or perhaps someone is saying, “I’ve really always identified myself as a person who speaks my mind. I want to express myself honestly, but I’m beginning to get some feedback at work from my boss that that is really not going to help me advance in my career. So I’m thinking maybe I should take a look at that, but I’m not so sure.” So he’s trying to figure out if changing something about the basic way that he has been interacting is important for him to work on.Or perhaps a young mother has been following the ways that female relatives have been telling her she needs to be dealing with her newborn baby, but she’s read some literature that maybe that’s not quite the right thing. So she wants to talk to the baby’s pediatrician about whether or not she should do something different, because she’s getting conflicting information.

VY: We’re moving into territory where the client is aware that there’s some potential need to change, reason to change, but they’re ambivalent. There might also be a reason not to change.
CC: Right. It’s so much easier to do things the way that we’ve been doing them all along. In the case of the young mother, it could be that going against the grain of what she’s being told by these other significant people in her life is something that, while she might think it’s important, maybe she doesn’t think she can pull it off. Maybe she thinks she’s not really capable of standing up to them and saying, “I’m going to bring my child up in a different way,” so it’s easier for her to say, “No, I don’t think it’s that important.”
VY: Throughout the course of counseling, assume you resolve this ambivalence in one way or other and the client decides, “Yes, I do want to cut back on my drinking,” or, “I want to quit my drinking,” or, “I want to lose some weight.” Then you move into the territory of whether they have the confidence to make that change.
CC: Exactly—whether they feel that this is something that they’re capable of actually doing. And if we look at, say, people who have decided that they want to stop smoking, many, many people can say, “I know it’s important not to smoke, but I have tried and failed so many times to stop smoking that I’m just not sure that I can actually do it. So maybe I should just keep on smoking because I really don’t want to fail again.” Now we’re now helping them take a look at the issue of confidence and capability.
VY: What is MI bringing to the table there? How do you help increase someone’s confidence or likelihood of making that change?
CC: One of the things that I would do is explore with these people any past attempts that they’ve had. If they’ve had any success at all, even if it’s just been for a day, I’d like to find out what helped them, or what happened that they were able to be successful even for a short period of time. I’d also want to explore with the person other areas in their lives where they have actually tackled some sort of challenge or made a change successfully, and help them talk about what helped them be successful at that time. Perhaps it was outside support from another person, or it was buddying up with a person to be able to pull off an exercise routine.I also help them determine what natural traits and characteristics they possess that help them tackle things in life that could be difficult, and how could they use those particular traits to help them in this particular area.

Another thing that helps with confidence is actually giving people sufficient information about how they might go about making this change, and helping them explore whether or not they think that would work for them.

Most of us are not going to step out into making a change unless we think we can pull it off, so to actually have an idea of how to go about it can be very helpful.

Offering Advice and Information

VY: As I said, Motivational Interviewing is widely used in healthcare and medicine, although our audience for this interview is mainly counselors and therapists. I think it’s just important to note that, say, in a medical setting, a healthcare provider might have very specific information about managing diabetes or quitting smoking. But also in counseling, if we have particular expertise in addictions, again, we might not tell them what to do, but we might say, “Based on our experience, this is going to be more likely to be successful than this.”
CC: If a person is saying, “I want to do this, I just don’t know how, and therefore I’m not confident,” we might say, “If it’s okay, I can give you some information on what has been helpful to other people, and from there we can see what you think about that in terms of it being useful for you.” I might present two to three ideas, then stop and go back to the client and explore again. “What do you think about that?” And see how they would work with that.So in addictions, I might say, “Some people find it helpful to do things like 12-step recovery and others find it helpful to go to specific treatment kinds of programs, while still others use things like web-based programs to help them deal with establishing abstinence and getting support. Other people have turned toward their faith, if that’s been something that’s important. So I’m just wondering, out of some ideas that I’ve presented, what ideas that brings up for you or what other questions that you might have.”

I’m always coming back to the client and checking in again, because ultimately the client is the one who’s going to decide.

VY: That again, is quite different from an approach where you say, “You really need to go into an inpatient program.”
CC: It’s very different from a prescriptive approach. I want to make sure, though, that folks listening to this don’t misunderstand: the counselor can actually provide specific recommendations, but it’s done in a way that ultimately our clients still know that they are the one making the choice. We’re reinforcing our clients’ autonomy.Let’s say that I have done an assessment with someone in relationship to drinking patterns and what kind of impact drinking has had in this person’s life. And let’s say that the client is now trying to decide whether or not he wants to do some harm reduction, or whether he wants to be completely abstinent. The client might ask me what I think, and it’s perfectly okay for me to give my point of view, but I would say it perhaps in this way: “Ultimately, you’re the one that’s going to make your choice. But from my review of your history and from what I hear about you trying to do moderation in your past attempts, it looks for me like going for abstinence is the right thing for you to do, certainly at this time. That’s my professional recommendation based on what I learned from your history. But again, I want to know what you think about that. Ultimately, you have to make the decision.”

What’s New About MI?

VY: It sounds very consistent with how a lot of therapists work in general. We generally don’t tell the client what to do. We think that we’re listening to them and being supportive. For the therapist who wants to integrate this into their general work with clients, what’s most new about this? When you are training counselors, what do you find really stands out for them about this approach?
CC: Particularly with seasoned counselors, what stands out as new for them is listening for when the client becomes uncertain again about addressing their target behavior—when they begin to shift and begin to have some doubt, perhaps, that they are capable of doing this or that it. It remains important to listen for that and realize that when we begin to hear that, we now need to shift and start to explore that uncertainty again and not act as if we’re continuing to move forward, because then we’re not really in sync with the client any longer.
VY: By that, you mean the client has been exploring the possibility of change but then hit a roadblock and start to get stuck back into ambivalence.
CC: Yes. They go backwards. They shift directions and move back into sustain talk. Let’s stay with the drinking example: say your client has decided that he wants to establish abstinence and he’s done that, and he’s been abstinent for three months and continued to work on possible barriers in supporting that.Then he comes in one session and says, “I’m doing really well with this, but I’m beginning to think that I just needed a break. I just needed to stop for a little while. I could probably go back to drinking again.” So he’s shifted directions. He’s said, “I’m thinking about this in a different way” which means that we have to now shift and begin to explore what’s happened and see where they want to go with this. Perhaps he has decided that the break is what he’s had and now he would like to try harm reduction or moderation. So now we’re attending to this in a new way.

VY: And the therapist needs to watch out for that tendency to want to kind of jump on the client, saying, “But you already decided this.”
CC: That’s exactly right.The temptation is to come in and try to convince the client, “You’ve made this decision. You shouldn’t turn back. You should keep going with this decision.” But then we will have moved into a position with the client where we’re not partnering with him any longer. We’ve decided that we’re the expert and we’re going to tell him what to do.

The other thing I think is new, in terms of really attending to it, is this difference between sustain talk and change talk. Motivational Interviewing really emphasizes that in a way that other counseling approaches doesn’t, and we’re really explicit about this. I find that this is new territory for counselors, to think about client language in this way.

In the years that I have been doing training, I have found that it’s challenging for people to pick up on change talk and to reinforce it. Counselors have to really start to tune the ear to pick up on change talk, to notice when that occurs and then shift direction and actually start to reinforce that change talk. Counselors often know the good client-centered skills, as you have mentioned. But listening for that change talk and beginning to reinforce that is often novel.

I think there’s something about us as therapists, and I think it’s our desire to know, and to know more detail. We get really seduced by the detail. We want to keep hearing more about the why-nots that are on the side of sustain talk. Our curiosity about knowing everything on that side of the world gets us in trouble sometimes, because when that change talk occurs, we really need to abandon everything that has occurred up until that time that has to do with sustain talk, and move ahead. It doesn’t mean that we don’t come back later and explore some of the barriers that the person might have talked about. But we do that once we’ve moved ahead and we’re saying yes to change. Now we may look at what gets in the way. But actually hearing the change talk and, when we hear it, immediately moving with it, can be a challenge.

VY: One way I’m hearing what you’re saying is, as therapists, we often like to look at people’s struggles and how they get stuck. It reminds me of an interview we did with Martin Seligman on positive psychology and psychotherapy, where he said that most traditional psychology is focused excessively on pathology and not giving equal focus on positive factors, on our strengths. So I’m thinking of it in that light, that therapists may get stuck on wanting to explore people’s challenges and problems and not give equal weight to hearing about people’s motivations for change and exploring that equally.
CC: I think you’re absolutely right. And in some ways, I think our initial training may have set us in that direction. To look at the positive side of this for us, we are really good at sitting with the struggles that a client has, at being able to understand it. And sometimes I think that strong capability that we have in that area might get in the way of us hearing those subtle changes of, “I don’t want to struggle this way any longer.” So we have to be very tuned into that.
VY: And sometimes therapists think, “Well, if you’re moving into just supporting them to change, that could be superficial.” I’ve seen you work, and I’ve seen videos of Bill Miller as well. And what strikes me is it sounds simple, but to do it well it’s really very nuanced. It’s very subtle and very strategic.
CC: Yes, very strategic. And there’s nothing more exciting to me than to have a client begin to embrace the changes possible and begin to believe in the capability that they can have in making that change and just watching that deepen. That, to me, is an extremely exciting thing to see happen. And I’ve equally seen the same thing when a client is with a counselor and they have started to say, “I’m really tired of talking about why I wouldn’t change. Now I would like to talk about why I would change and what I’d like to do about it.” When the counselor doesn’t listen to it, the light goes out of the client and the interview. It’s like the client gives up. So it’s a very special way of working with people, to reinforce client autonomy and to realize the extremely valuable role that the therapist has in guiding this process. If clients already knew what to do to make change, they wouldn’t be sitting in our offices in the first place.It’s very rewarding to work in this way and to watch clients become excited about themselves and what they can do. They often will say, “Thank you so much for telling me what to do,” when we’ve not said anything about what to do. They’ve come up with those ideas themselves, but they kind of think that we have. It’s a very fascinating thing for me to watch, and I often will say, “No, you’re the one that came up with that. I didn’t tell you what to do at all. You came up with that idea.” But they appreciate the process.

VY: Again, the counselor or the therapist has expertise in the process of change but they’re not the experts on clients’ lives and what clients should do to live their lives.
CC: That’s exactly right. Our role is to help our clients figure that out and to put words to that, so that they can really solidify that and deepen it.

MI with PTSD

VY: You work in the VA, where of course they’re very concerned about treatment being effective and using empirically validated approaches. I know there’s been a lot of research on Motivational Interviewing. Are you familiar with the research?
CC: I’m familiar with the research on Motivational Interviewing. There’s lots of evidence that clients make more changes in whatever the target behavior is when Motivational Interviewing approach is used rather than some other standard approach. Motivational Interviewing has a specific niche, and that niche is resolving ambivalence to change. I can give a brief example of how I use that in my work.I work with folks who often have had long histories of problems related to trauma, particularly sexual trauma in my line of work. They have posttraumatic stress disorder and have developed a number of behaviors, primarily avoidant behaviors, to help themselves feel safe in the world. And at some point in time they’ve come to my office, either self-selected or by a referral from someone else in the hospital, because they’ve screened positive on a PTSD score or they’ve said something to their doctor, and the doctor has encouraged them to see me. So now they’re in my office and we’ve done some history. We’re now at the place of the client deciding, “Am I going to do something about it?” The target behavior is this avoidance behavior, perhaps, that’s come from the PTSD, and clients now have to consider, “How important is it for me to actually do something about this? What’s that going to mean for me and my life? Am I willing to go through what might be a painful process to address this? Am I willing to face these fears in order to make some changes in my behavior?”

I’m using Motivational Interviewing at that point toward clients letting me know yes or no. “Am I going to work with this or am I not going to work with this?” That’s the engaging, the focusing, and the evoking part of Motivational Interviewing processes that we use.

Let’s say a client comes to a clear yes: “I really need to get on top of this because my 25-year-old son is saying to me, ‘I won’t leave home until you are less fearful,’ and it’s not okay for me to hold my son up in his life.” So the importance is not based so much on what the client wants for herself; it’s based on what the client wants for that son. It’s a clear value issue around the son. The client is now saying, “Okay, I’m willing to do this because it would benefit my son. And perhaps I’ll get some benefits, too, but it’s really so I don’t hold my son up in life.”

Now I have a clear yes, and we’re going to move into talking about the possible ways that this client can actually go about doing this work. And that’s where I can then present the evidence-based therapies that are available, either through me or through our institution, so that the client can then decide which of those evidence-based therapies she will use. So I have done the first task of Motivational Interviewing, which is resolving ambivalence, and now the person moves into some other specific form of therapy.

VY: Which you might provide or someone else might provide.
CC: Exactly. I can then review what we currently offer. I’m still using Motivational Interviewing because I’m letting her know the possibilities, and then she can decide from those possibilities which one do she thinks she would like to try, what might work best for her.
VY: It’s a nice example because it shows how you can integrate MI into a traditional course of therapy and also shows how you can use it with a problem. It’s not as circumscribed as a drinking problem or a specific healthcare issue. It’s a psychological problem that results from PTSD and fear. But it’s circumscribed enough that you can use MI to decide whether or not a client wants to tackle it or not.
CC: Right. So then the client has made a clear, informed decision. I continue to talk about Motivational Interviewing as informed consent. The client is thoroughly exploring the issue and making the decision, and that’s informed consent.

Teaching MI Skills

VY: Another thing that’s impressed me about it from what I’ve heard primarily from you, Cathy, is the training in Motivational Interviewing is very detailed. A lot of training in our field is more theoretical or overview focused, but from what I understand, to be certified in MI or as a trainer, people really look at your work and you get very specific feedback.
CC: Right. I always speak to the certification issue. There’s no particular certification process for people learning Motivational Interviewing, but many people go through training with folks like myself who provide training in MI. And it’s not just coming and sitting through a lecture; it very much involves practicing all the parts of Motivational Interviewing. Then, working with a person who can provide feedback and coaching by actually listening to interviews is what increases trainees’ competency in using Motivational Interviewing.
VY: When you’re listening to someone’s interview, what are you listening for?
CC: Actually, there’s a particular scoring guide that many of us use who provide coaching and feedback. I’m listening for whether or not the person is using what we call MI-adherent behaviors, using open-ended questions, using a higher reflection-to-question ratio, avoiding telling the client what to do, working fully to understand what’s happening with the client’s point of view.We’re listening for whether or not the therapist is keeping the focus on the direction in the interview; focusing on the target behavior, helping the client fully explore and understand the current issue, allowing the client to explore their own ideas about change, and helping the client deepen the meaning of making change.

There are many counselors who are very good at guiding the direction of an interview. They can keep a client on target. But they don’t necessarily do very well at exploring the client’s understanding, exploring the client’s own ideas for change, really validating. They might hear a client’s idea and immediately say, “Yeah, that’s a good idea, but let me tell you a better one.” That statement is completely non-adherent.

We’re listening for all of those things in an interview and providing very direct feedback on what the counselor’s doing. We know that the only way to really develop skill in Motivational Interviewing is to get feedback.

VY: I think we’ve really covered a lot of material here, at least to introduce people to some of the core concepts of MI. If folks are interested in learning more, where would you direct them?
CC: There’s the Motivational Interviewing website, and trainings are listed there. I certainly provide training myself. The trainings that I provide throughout the year are all listed on my website. There are a number of trainers who provide workshops throughout the United States. It’s also possible to engage a trainer to come to an area and provide a two- to three-day training for a group of people that someone organizes locally. So there are a variety of ways to go about getting training.
VY: You’ve been training therapists and counselors in MI for a long time. How have you evolved personally in your understanding and skills?
CC: Yes, I’ve been practicing Motivational Interviewing since 1992 or so, and I’ve been training since 1995. It’s changed me as a therapist very much in terms of my ability to listen, to not judge the client, to really be accepting of the client and the struggle that the client is bringing to the table. Again, that’s basic Rogerian counseling, and it sounds simple. You can spell out the principles in a couple sentences. But it’s very subtle and it’s not easy to do.
VY: Are there gradations in that ability to accept clients where they’re at? Do you see yourself doing that more, better, deeper now than you did 10 or 15 years ago?
CC: Yeah, I do. I think that when I became aware of Motivational Interviewing and I began to learn the very specific ways to have a conversation with a client using MI methods, I became even more aware of the strengths that clients bring to the table, and I became even more appreciative of clients knowing what is right for them, when it’s right for them, and accepting choices that clients make, whether or not I thought they were the right choices for the client or not.

I feel calmer as a therapist working in this way. I’m not disengaged from the process or detached from it at all, but I’m fully appreciative that responsibility for change lies with the client and that I have a very important role to help that client fully explore this possibility, but that ultimately, I’m there to respect the decision the client makes. It’s a very refreshing and calming way to work. I think the feedback from clients really reinforces that for me. It’s not a struggle.

Alan Marlatt on Harm Reduction Therapy

Posted on by rezendevknowfully.com

Harm Reduction Defined

Victor Yalom: We're here to interview you today about your work with addictions, and specifically your contributions to the field of harm reduction. Just to get started, the name harm reduction gives a hint of what your approach is about, but maybe you could say a few words to introduce the concept.
G. Alan Marlatt: We are basically trying to support people that have addiction problems. If they want to quit, we'll help them do that. That's our relapse prevention program. If they would like to be able to reduce their drinking or drug use-harm reduction—we want to support them there too.

Many people with alcohol and drug problems are not getting any help, and I think part of the problem is they don't want to identify as drug users, or if they're using illegal drugs, they're afraid they're going to be arrested and put in jail or something like that. They're holding out. But if you talk about moderation, many people say that's an enabling strategy.
VY: Many professionals.
GM: And others. So it’s a very controversial topic, but basically my position is, “We’ll help you, whatever your goal is. You want to quit, we’ll help you. You want to cut back, we’ll help you. We’re not going to shut you out.”
A lot of the traditional treatment programs are saying, “Unless you’re totally committed to abstinence, we’re not going to work with you.”
A lot of the traditional treatment programs are saying, “Unless you’re totally committed to abstinence, we’re not going to work with you.”
Rebecca Aponte: If somebody wants help cutting back, is that something that they can work on with a harm reduction therapist for life?
G. Alan Marlatt: With some people it's for life. Let me give you an example of a case. This is a woman that was being treated by a psychiatrist for depression at the University of Washington. The therapist called me up and said, "I've been seeing her for about three months, and today I found out that she has this drinking problem. So, I said to her, 'I can't really help you or continue to treat you unless you go into alcoholism treatment, and I don't know how to do that.'"

VY: He doesn't know how to do alcohol addiction treatment.
GM: Right. Most psychiatrists don’t know how to do that; it’s not part of their training. So he wanted me to do an evaluation of her. When she came in to see me, she’d already been to the alcohol treatment center that the psychiatrist referred her to. I said, “How it’s going?” She said, “Everybody’s telling me something different. The psychiatrist said I was probably drinking a lot to kind of self-medicate my depression.” And that was partly true.

Then, when she went to the alcohol treatment center in Seattle, they said, “No, your alcoholism is causing your depression. Unless you are into our abstinence-based program, it’s just going to continue. Are you ready?” She said, “No, I’m not ready. This is the only thing that works for me and I know it’s causing other problems, but I’m not ready to give it up.”

So she was stuck in the middle. For a lot of these kinds of people, harm reduction therapy is the best alternative. So I said, “Let’s do harm reduction therapy. I can help you keep track of your drinking, and see what’s going on.” So she agreed to do that. A lot of people at that point will drop out. If all they have are abstinence-based alternatives, they’re not going to do it.

But she agreed to do it. She worked with me for three months and we kept track of her drinking. She reduced her drinking significantly.
VY: What was her goal?
GM: Her goal was to drink more moderately and to figure out what was going on in her marriage about drinking, because her husband said, "You're a chronic alcoholic and unless you stop drinking altogether, I'm going to leave you." That made her more angry and depressed. She tried to stop drinking, and then when he would go out of town, she would get loaded—this kind of thing.

We finally figured out there was a lot going on in terms of the marriage and her anger. Then I taught her meditation, which was the most helpful strategy for her. Then, one day she was going shopping and she saw her husband in a car embracing another woman and it just made her start drinking again. She said, "I can't do this anymore."

She went to a meditation retreat center in France—Plum village, the Thich Nhat Hanh Center. You go there, you take these precepts. One of them is no use of intoxicants while you're here. She said, "I took that and I thought, 'That's it. I'm never going to drink again.'" She's been now abstinent for five years.

So harm reduction was the bridge to get her there. If you say, "You've got to stop now," a lot of people go, "I can't stop now." But if you start getting them into a harm reduction program and they realize they can reduce their drinking and begin to figure out what their triggers are, they feel a lot more confident that if they want, they could quit. That's what happens a lot of the time.
VY: Getting back to the basics of it, what do you mean by harm reduction and how did it originate?
GM: I did a sabbatical at Amsterdam in the early '80s. That's where harm reduction originally developed, because they were the first country to realize that injecting drugs can increase HIV and AIDS—so why doesn't the government provide needle exchange instead of [the addicts] sharing needles, which spreads HIV much more readily? This was when HIV and AIDS really broke out and a huge number of people died. So they said, "If people are going to use, we want to help them stay alive. We want to reduce the harm." The needle exchange program was really the first type of that.

In Vancouver, Canada, where I grew up, there are many homeless people living in the lower east side that are injection drug users, and a lot of them are overdosing and dying.

What did the mayor's office do? After some persuasion from harm reduction specialists, they opened a safe injection center. This is where, instead of shooting up in the alley and not knowing what you're getting, you can go to this site. They'll give you clean needles. They'll allow you to shoot up there. There are nurses and doctors available if they need help. Since they opened that, the fatality rate has dropped. Of course, many people say, "Why is this happening? You're just enabling them to continue using."
VY: Right. "This is illegal and the government is helping them do something illegal."
GM: Exactly. The second program in Vancouver that just started and is also having good results is basically prescription heroin from doctors. Of course, that started in England years ago. Physicians there called it the medicalization approach. If they were dealing with a heroin addict, they could say, "Look, we'll prescribe you heroin while you're doing treatment because we don't want you to overdose from buying it on the street where you don't know how potent it is." These are harm-reduction kinds of approaches.

Another example is methadone treatment; that's harm reduction because you're reducing the rate of potential for overdose fatalities.

The Bar Lab

I was interested in applying it to alcohol problems, which means moderate drinking. Mainly we’ve been working with college students who are binge drinkers, because the NIH report has been showing about 1,400 to 1,500 college students die every year from alcohol-related problems—overdose drinking, car crashes.
 
At the University of Washington, there was a recent case of a student who died. A 19-year-old freshman was living in a dormitory, and a woman that was his friend just turned 21. What do you do when you turn 21? You want to have a party because you can drink legally—even though her friends were 19 or underage. So they go, “Where can we go and not be caught by the dormitory advisors and things like that?” If you catch you drinking and you’re under 21, you could lose your room. So one guy said, “Hey, there’s a balcony on the seventh floor. Let’s bring all our alcohol up here.”
 
 So they took their vodka and rum and everything else up. There were six of them. They said, “We’ve got to drink quickly just in case—otherwise we’ll get caught.” They all got loaded pretty fast, and the guy who died was sitting on the edge of the balcony telling a funny story, lost his balance—head-first down in the cement, killed on impact. His blood alcohol level was 0.26. In Washington state, 0.08 is the legal limit. He was triple that.
 
 We found out from his family and friends that he wasn’t a big drinker in high school. Once he got to college and all of his friends were drinking, he just went overboard.
 
 So harm reduction for college students means we’ve got to train you how to drink more safely, even if you’re underage—that’s when the highest risk occurs. We developed a program called BASICS—Brief Alcohol Screening and Intervention for College Students.
We’re teaching them, “Just like safe driving, this is safe drinking.”
We’re teaching them, “Just like safe driving, this is safe drinking.” Your blood alcohol levels, what’s going on, how alcohol affects you—we teach them all that. We bring them into our bar. We have an experimental bar on campus called Bar Lab. We give them drinks.
VY: This is like John Gottman's Love Lab.
GM: Yeah. This is the Bar Lab. It's a cocktail lounge on the second floor of the psych building. What we do there is bring students in and give them drinks. They can drink anything they want for an hour—usually about 12 to 15 students. They're usually getting pretty loose and playing drinking games. Then we tell them, "Guess what? None of the drinks that you had had any alcohol in them whatsoever. They're just placebos." They go, "What?"

We tell them, "Look, when you go drinking, three things are happening: what your actual drink is, number one; what the setting is, like a bar, there's music or whatever; and most importantly, what your set is—your expectancy about how alcohol's going to affect you. Those things make for big placebo."

So, people who go through this—we call it the "drinking challenge"—end up drinking about 30% less after they go through that particular program.
VY: How do you get them to agree to do the program?
GM: They get paid for follow-ups and assessments over a four-year period—only about $200, but still. We had an abstinence-based alcohol awareness program on our campus, and they would show car crashes and things like that—people who get killed. And they were trying to say to people, "You can't drink legally until you're 21." Who showed up for that program? Hardly anybody—maybe 2% of the students.

But if we go into the fraternities and the sororities and the dormitories and others and say, "Would you be interested in a program that would help reduce your hangovers and your driving, sexual problems and things like that?" They all go, "Yeah." So you bring them in.

So harm reduction is typically user-friendly. It's not saying, "You've got to stop or we won't talk to you." People with addictive behaviors—there's so much shame and blame and stigma. They don't want to show up. Instead, we're saying, "We're going to meet you where you are. We're not asking you to quit right away. We're just saying let's talk about what your drinking or drug use is like and see what you might want to do. We'll try and help you, whatever your goal is"—rather than confronting them and saying, "you've got to quit."

Moral Objections

VY: Why do you think there's such vociferous objection to the harm reduction approach?
GM: Many people buy into the moral model of drug abuse, the war on drugs—it's called a black-and-white model. Either you're abstinent or you're using. You're an addict. There's nothing in between. So the door is pretty tight. Kurt Olkowski, the new drug czar that we just got under Obama, said that the war on drugs has failed. Thank God, because the previous administrations under Bush and Nixon said, "Lock them up. If they're using illegal drugs, punish them." We now have 2.3 million people locked up in this country, which is more per capita than any country in the history of the world. Sixty percent of them are there either directly or indirectly incarcerated because of drug or alcohol problems.
VY: It's clear you take issue with the moralistic approach.
GM: Yeah.
VY: Is harm reduction a countervailing philosophy?
GM: It’s a public health approach.
VY: Is it a more scientific, research-based approach?
GM: Yes, it is based on research, and there are more and more studies coming out that show that it is really helpful. It's working. Our BASICS program for college students is now listed on the national registry for evidence-based practices. We've got about 2,000 universities that are now using it. That's really working. People don't like to call it harm reduction. They would call it an alcohol skills training program or something.

Alan Leshner, who's the director of the National Institute on Drug Abuse, published an article last year saying, "Drop the term 'harm reduction' because it creates so much controversy. Let's call it something else"—sort of like the word "communism" or something. Up until recently, if you were presenting a paper at the APA or any other conference where there was sponsorship from NIH, if you used harm reduction in the title, it was eliminated. They said, "No, we won't let you talk about it."

I've run into this a lot. I've given talks about harm reduction where half the people walk out of the room while I'm talking. Huge resistance.
VY: Why do you think that is?
GM: They're from the moral perspective and they think all the harm reduction technique is doing is enabling people. I received an award yesterday, and one of the people that gave me the award told me he remembered when I was first talking about harm reduction and people claimed I was murdering alcoholics and allowing them to die.
…when I was first talking about harm reduction…people claimed I was murdering alcoholics and allowing them to die.


What we’re doing, like in Housing First, is trying to keep these people alive. That’s what the research has shown. So I think harm reduction is going to take off under the new administration. Ninety percent of the people who have alcohol and drug problems aren’t getting any treatment unless they’re busted for something. How are we going to bring them in? We’ve got to allow harm reduction to be a middle way. 
VY: You're not against abstinence as a goal.
GM: No. We’re for both. We’re just trying to get more people in the door.
VY: You're for both abstinence and moderation.
GM: We’re for whatever your goals are. We’re going to help you do that.
VY: If someone has a goal of moderation, but is unable—some people apparently can't control their drinking—
GM: You’ve got to put them through a program, and then they finally get to realize that they can’t do it even though they’ve had the best program. If it’s not working, they’re much more willing to consider abstinence. You’ve got to try something.
VY: Do you agree with this idea that there is a subset of addicts that just can't do moderation?
GM: It depends on the moderation program. Now there are more pharmacology treatments coming in to help people moderate drinking, and many more cognitive behavioral skills training programs. A lot of people can't achieve moderation if they just try and do it on their own. If they get into a good program that teaches them the skills, like how to use a blood alcohol level chart—if you're a male or a female, how many drinks over how many hours, what your blood alcohol level is going to be—what are you going to do instead of drinking? You want to keep your BAL lower. A lot of the young people that we work with that do binge drinking—they drink two beers in 15 minutes. They don't feel anything so they drink two more, and things like that. We tell them to slow down. Drink two beers and wait half an hour. Then they can actually feel the effects of these two beers. "I don't really need any more," this kind of thing.

We're not telling them that it's all bad. We're just telling them it can be harmful.
Alcohol is biphasic. The initial effects are euphoric, but if you keep drinking, it gets dysphoric.
Alcohol is biphasic. The initial effects are euphoric, but if you keep drinking, it gets dysphoric.You start losing your coordination. You have blackouts and other kinds of problems. What is your limit here, where one more drink is not going to make you feel any better? You learn that. You stick with it. That's been working very well.
RA: Do you see a lot of parallels between the opposition to the harm reduction approach and the opposition to anything other than abstinence-only sex education?
GM: Totally, yes. It's the same issue because they're saying, "If you teach people about safe sex and condoms and things like that, that will enable higher amounts of sexual activity, so we should promote abstinence." But those programs are not working.

It's just like the DARE program—the drug abuse resistance education—totally abstinence-oriented. Now they're finding that kids who went through the DARE program in school are doing worse in terms of alcohol and drug use. Harm reduction applies, I would think, to what we call the 3 Ds of adolescence-the three dangerous drives—drinking/drug use, dating (sexual behaviors), and driving. So if you teach people how to do those things more safely, whether it's sex, driving or drugs, you're going to reduce harm. There's plenty of research to show that it's true, but the political resistance has been amazing.

For example, one of the big harm reduction programs we have done in Seattle is for homeless alcoholics, people living on the streets who are drinking. We worked with the Downtown Emergency Services Center, which provides housing for homeless people. There was a program in Canada called Housing First where they give people housing and let them drink in their housing if they want. Compare that to what they tried in New York, in which people had to quit drinking or they wouldn't get the housing, so almost everybody got expelled or kicked out because they couldn't give up drinking.

So the Seattle program, which we received a big grant on, basically asked, "What's going on?" We wanted to compare people who got housing right away with the people who were under waitlist control. The people we looked at were selected by the King County and Seattle government; they were people that had the highest health costs over the last year. These were very sick people; the average life expectancy for them is about 42 years. So the government referred these people, who either got the housing right away or were on the waitlist. In our program, they were allowed to drink in the public housing and the opposition in the media was huge. "What? We're using taxpayers' money and letting them drink? What is that all about? You're just enabling them."

One year later, we found that the people who got the housing had reduced their drinking. For many of them, having housing gave them more reason to live. As we published in the Journal of the American Medical Association, the most important thing was the health cost savings of four million dollars over the first year. All of a sudden, people said, "Maybe harm reduction saves money compared to what we were doing before." We keep getting these flips in terms of reactions to harm reduction.
RA: I've heard you mention before that therapists can unwittingly enable their clients' addictive behaviors by ignoring the addictions that are going on: treating the emotional issues that they bring into their sessions, but not talking about their alcohol or cocaine use.
GM: Yeah. A lot of people do have both kinds of problems, and they’re using alcohol or cocaine or whatever it is to self-medicate when they’re depressed or when they’re anxious. That’s still a big split between the mental health and the addictions fields, even though many people have both kinds of problems. How are we going to approach them and teach more mental health folks to think, “Hey, there are alternatives here”?

Harm reduction is one of them, and brief interventions have become very popular now. For example, Tom McLellan, who is the associate drug czar/psychologist that everybody knows, was saying we should train primary health care physicians at general hospitals, so that when people come in with whatever their medical problem is, if they have an alcohol, smoking or drug problem, do a brief intervention. It doesn’t mean confront them, but just say, “Hey, have you thought about doing something about this? I have some information for you. Try it out. See if it works.”

They include harm reduction programs to cut back as well as programs to stop. That is very radical, but it has been happening in trauma centers around the country. In the Seattle trauma center, if people are brought in from a car crash that involved drinking or something, Larry Gentilello, a physician there, would do a brief intervention, meet with the person once their medical care is handled. “Hey, there are some programs that could help you cut back or quit drinking. Are you interested?” A lot of them said, “Yeah.” The trauma center would give them the information, and provide the referral. That turned out so well that now all trauma centers around the country have to show that they utilize brief interventions in order to get their license. That includes harm reduction.

I think we’re going to see more of it because, first of all, it works.
The research is very strong. It saves lives. It saves money.
The research is very strong. It saves lives. It saves money.It gets more people on board.

Right now, most people with these problems are just staying out. They go, “All there is is Alcoholics Anonymous. I went one time. I don’t like it, and there’s nothing else that I know about.”

Harm Reduction in Psychotherapy

VY: Let's get into the nitty-gritty of how a typical psychotherapist, who doesn't specialize in drug and alcohol use, may deal with a patient struggling with an addiction. How do you start applying these principles in the course of counseling and therapy?
GM: First of all, you’re going to ask the person what’s going on in terms of their alcohol or drug use. What are the risk factors? We adopt a bio-psycho-social model. Biologically, you want to know maybe the family history and alcohol or drug problems. You want to know about whether that’s going to increase their risk. Then you would go on to psychological issues, what we call psychological dependency on alcohol or drugs. Why do they think it’s helpful, and what are their outcome expectancies about drinking or drug use?
VY: So you ask why they think it's helpful.
GM: Or harmful. We want to look at both sides. We want to meet them where they’re at, enter their world. We use a lot of motivational interviewing.
VY: Yes, it seems very similar to motivational interviewing.
GM: So we're trying to figure out whether this person is in pre-contemplation stages of change or contemplation, or looking at possible plans of action—and matching our intervention with that. You can determine that pretty easily. Have they thought of doing anything about this? What do they think of the pros and the cons [of their drug or alcohol use]?
VY: Can you give an example of how you match an intervention to where they are?
GM: If they're in pre-contemplation, we're just going to try to talk about, "Did you know that the amount of smoking that you're doing is going to increase your risk of lung cancer and emphysema? Are you aware of this?" We try and enhance awareness of the risks. And then if they're in contemplation—
VY: Which would mean they're contemplating quitting?
GM: Or they don't know quite what to do. They're going between the pros and the cons: "Maybe I could quit, but I don't know what's the best way to quit. Maybe this isn't the right thing to do." That's when we meet them and help them look at the reasons why they like drinking and what some of their concerns are about it, and then try and move them on to the preparation and action stage.

In the BASICS program with college students, we just meet with them twice, one on one. In the first session, we give them feedback about their risks. They've filled out all these questionnaires so we know about family history and expectancies. We know about their cultural factors. We give them feedback in a friendly way. We could say, "Hey, you said that 80% of the students at this university drink more than you—actually, you drink more than 75% of the students."
VY: You're giving them some data.
GM: Giving them feedback, but in a friendly way. So they're getting a lot of feedback and awareness. And in the second session, it's the action plan. "What are we going to do about this?" We don't tell them what to do. We collaborate with them. What have you thought about doing? One young woman said, "In my sorority we usually drink and get drunk Thursday, Friday and Saturday nights. I was thinking of maybe not doing it Thursday night." We would support that—something that they come up with.
RA: Although it's not something that's necessarily spoken to directly, it sounds like this approach has a high sensitivity to the shame around addiction.
GM: Oh, yeah—shame, blame, guilt, stigma, moral issues. We're trying to let people know what their level is, how many other people have this kind of problem, and what kinds of things could help them. If they would like to quit, we'll say, "Great, we can put you in an abstinence-based program." Most of them are saying they just want to cut back. They're very positive about these kinds of skills we teach them. After we bring them in a bar lab and give them placebo drinks, then we teach them about blood alcohol levels and give them charts. We have them keep track of their drinking for two weeks so that we can see which days and what situations, whether they drink by themselves—which is more dangerous than social drinking—things like that.
We just give them a lot of feedback, but not in a punitive moralistic way: "What can you do to change? We'll try and help you."
We just give them a lot of feedback, but not in a punitive moralistic way: "What can you do to change? We'll try and help you."
VY: You're not coming at it from a moralistic way, but you do have some stance. You have an idea that if people are drinking in a way that you define or you think is destructive, you would like them to change that.
GM: Sure, yeah. It’s pragmatic. That’s where we’re coming from. It’s not moralistic.
VY: One thing I noticed in the video I saw of you with this black male, you got into really nitty-gritty details. He said he wanted to quit, but you really drilled down into, "What does that mean, to quit? What's your first step?" He said, "I'd go to the program." "What do you have to do to go to the program?"
GM: Right—break it all down into different steps. Also, we found that what triggered his relapses was, whenever he had cash, he'd go down to "buy a pack of cigarettes," and, "There's my beer"—these kinds of things. We're trying to teach people cognitive behavioral strategies around things that can set you up for relapse. Whether you're doing harm reduction or abstinence, there can be occasions where you just do way too much. What are the steps that lead up to that? We're using a lot of mindfulness and meditation to get people more aware of their choices.

Victor Frankl wrote this saying: "Between every stimulus and response, there's a space. In that space is our power to choose our response."So we use this idea in our work, and it's turning out to be very helpful, especially for people trying to stay on the wagon.
VY: How have you integrated mindfulness? It seems like a hot topic that's integrated into many approaches these days.
GM: Yes, mindfulness-based stress reduction—Jon Kabat-Zinn's work inspired us. I'm a good friend of his. Zindel Segal's mindfulness-based cognitive therapy for depression is very effective. Ours is mindfulness-based relapse prevention. All these programs are group-based, outpatient weekly programs for eight weeks.

We've gotten funding from the National Institute of Drug Abuse to evaluate the program, and we're finding that it's working pretty well for people with chronic alcohol and mental health problems. Of course, it's voluntary, so if people don't want to do it, that's fine, but a lot of people, once they talk to their friends who have gone through it, they go, "Hey, I'd like to do that." It's relaxing. It's stress reduction. It also gives you a different perspective on craving.

In the last study, we found that people in the control group, the more depressed they were, the more their craving went up—this was in an abstinence-based program—but if they went through mindfulness when they were more depressed, craving did not go up. The depression and craving was kind of disassociated. We're very enthusiastic about that.
VY: How do you explain that?
GM: Because mindfulness gives you a little bit of a different perspective, so you don't over-identify with situations like when you're depressed or feeling like you have to self-medicate to feel better. It gives people more of a choice. It doesn't mean they always do it, but a lot of times they do.

If you think of addiction treatment, the 12-step program, which is very popular, is basically Christian-based. The word God shows up in six of the steps, although they say the higher power could be anything. But a lot of people don't connect with that. The mindfulness program is more based on Buddhist psychology. It's a whole different approach. It's also very consistent with harm reduction—the middle way and things like that. It basically tells people there is another way. Instead of the 12-step program, you could do the eightfold path in Buddhism—right mindfulness, right activity, all that kind of stuff. So I think it's an alternative.

Carl Jung originally said that a lot of people with addiction problems are kind of like frustrated mystics. They're looking for an altered state.
Carl Jung originally said that a lot of people with addiction problems are kind of like frustrated mystics. They're looking for an altered state. Many of them are hooked in the spirits in the bottle, where they're really looking for another spiritual approach. I think mindfulness is another pathway. A lot of people relate to that pretty well.

The Disease Model of Addiction

RA: Do you have a problem with the disease model, from the standpoint that it classifies a person as an addict in a way that integrates into their self-identity?
GM: Yes. Phillip Brickman identified four models: the moral model, the disease model, the spiritual model and the cognitive behavioral model.

The disease model says, "You have a disease and it's due to factors beyond your control: your genetics and your physiology and it's all the same disease for everybody, so we're not going to give you any individualized treatment. We're going to put you in a 12-step program"—which also buys into the disease model. The theory is that there is no cure whatsoever. All you can do is arrest the development of the disease by maintaining abstinence. If you have one drink, it's a relapse. In AA, you have to go back to the beginning again.

In harm reduction, we take the attitude, "Hey, lots of people have slips. Let's look at what happened. You made a mistake. How can you learn from it?" We're not saying, "You've got to go back to the beginning."
RA: That's very shaming.
GM: It's very shaming, yeah. I asked a lot of the disease model people, "Why do you say that there's no cure?" They said, "If there was a cure, people could go back to drinking. We don't want them to do that."

Even though the research at NIAAA—the National Institute in Alcohol Abuse—shows that quite a large percentage of people who have what we would call alcohol dependence, alcoholism, later moderate their drinking and do fine.
… a large percentage of people who have what we would call alcohol dependence, alcoholism, later moderate their drinking and do fine.
They don't want to say that. The disease model says that's enabling. I'm much more in the cognitive behavioral model.
VY: So you don't buy into the disease model at all.
GM: I don't want to put people in jail and say that they're moral failures. Sure, they have a problem—but for me, the disease model is: if you're a heavy smoker or a heavy drinker, there are potential disease consequences. You could develop cancer. You could develop cirrhosis. Is what you're doing a disease?
VY: Is the act of reaching your hand out and picking up a drink caused by a disease?
GM: It's a habit with potential disease consequences. In one of my most recent books, The Complete Idiot's Guide to Changing Old Habits for Good, we talk about changing old habits for good. Habits are what's driving this. It has disease consequences, totally. We're talking a huge health problem. But just to say the whole thing is a disease—what's the point?
VY: You haven't convinced everyone, obviously.
GM: No, of course not. But we’re out there. There are more and more people coming over to the cognitive behavioral model because, treatment-wise, that’s what is most effective.
VY: So you consider your approach consistent with the cognitive behavioral model?
GM: Oh, yeah. Many people call mindfulness a meta-cognitive coping skill, so it’s consistent with the cognitive behavioral approach. Plus lots of research shows that it’s stress reducing.

The biggest trigger of relapse is negative emotional states. People are upset. They’re angry. They’re depressed. They’re anxious. They want help from the drug. So meditation is an alternative way of giving them stress reduction. That’s what a lot of the patients that we’re working with are saying: “Wow, this is really helping. I’m meditating and giving myself a choice instead of giving into my cravings.” We’re showing a big reduction, as I mentioned before, between negative emotions and craving for relapse risk.

Consumer Choices

VY: I know back in the days, they tried to study and come up with an alcoholic personality or an addictive personality, and it seemed like there wasn't too much success with that.
GM: The main kinds of personality factors that keep coming up are sensation seeking—people that crave the high, altered state—and self-medicating—what they call coping. Those are the two main personality traits. Some people have both. That does increase the risk.

There are personality models. Right now, NIDA and other people are saying, "Addiction is a brain disease. It doesn't matter what drug you're using—it's all releasing dopamine in the brain. The pleasure centers are lighting up. We need pharmacotherapies that can reduce the effects of these different drugs or replace them, whether we're talking about methadone or any of these other kinds of things."
VY: What do you think of that?
GM: It may be helpful. Some of the medications do reduce craving on the short run. I think if we combine that with mindfulness, maybe the two of them would work together.
My position is, if you think something is going to work for you, try it.
My position is, if you think something is going to work for you, try it.It could be a pharmacotherapy. It could be psychotherapy.

In the addiction treatment field, there was Project Match that came up a few years ago. They were saying therapists should match patients with a particular type of therapy that the therapist thinks would work. In Project Match, they assigned hundreds of alcoholics to get Alcoholics Anonymous, cognitive behavioral therapy, or motivational enhancement interviewing. Those were the three groups. They followed everybody up for two years. They found—guess what?—there was no difference. All three groups did equally well.

What really worked the best was therapeutic alliance: if there was a good relationship between the therapist and the client, it worked.
VY: This has been the finding in all of psychotherapy research.
GM: Yeah. So I think instead of doing treatment matching, we should switch to consumer choice. People come in: “Hey, I’m interested in getting some help. What have you got?” There are some programs that are saying, “We’ve got a lot of different programs here. I’ll show you some videos. Here’s what’s happening with 12-step programs. Here’s a cognitive behavioral program. Here’s something on moderation management. Take a look and see what you think might work for you and have a backup.” Give people a choice of pathways.
VY: Back to being pragmatic.
GM: Back to being pragmatic. "If the thing you're trying doesn't work, there are other things you can try. Don't give up." The average number of serious attempts that smokers make to quit before they are successful is twelve. Twelve attempts! So people that have tried to quit smoking and say, "I can't do it. I've tried it three times"—I tell them, "You're not even there yet. Each time you learn something."

Therapeutic Mistakes

VY: What do you think are some of the typical mistakes that therapists make if they don't specialize in working with addicts?
GM: Like the psychiatrist I was telling you about earlier, a lot of them say, “I can’t handle this so I’m going to refer you to alcohol treatment. Until you get that under control, I’m not going to see you anymore.” That happens so much. It’s the wrong thing to do. People just get stranded. They get caught. They don’t know where to go.
VY: What would you tell the therapist to do?
GM: Integrative approach: look at addictive behaviors like any other behavior issue. Read about it, get some training, take some courses and things like that; don’t leave these people stranded.
VY: If someone's having problems with anxiety, you don't say, "I don't treat anxiety. You've got to go to an anxiety program." You integrate that into the treatment
GM: Not being able to see how the addictive behavior and the mental health problem relate to each other—thinking they're separate diseases. In reality, they're often extremely interactive. One is relating to the other—like the person with depression is trying to self-medicate and he gets caught in between. I think that is the main thing.

Sometime after that psychiatrist called me, I asked him, "How much training in alcohol and drug problems did you get when you were in medical school?" He said, "One half day." Christ. Of course they don't know anything about it.
VY: That's amazing.
GM: Yeah. That's the biggest issue—even in psychology. When I was a graduate student in the late '60s, I said to my professor at Indiana University, "People are studying behavioral therapy and they're doing all this kind of work with different behavioral problems. What about drinking as a behavior problem?' He said, "You don't want to get into that field." I said, "Why not?" He said, "The addictions field is very low prestige. Why don't you get yourself a real problem like snake phobias?" That's what was going on then.
VY: As a social policy health problem, there are a lot more people with problem drinking than with snake phobias, let alone snake bites.
GM: I said to my professor, “I don’t know anybody with a snake phobia, but I’ve got a lot of people in my family with heavy drinking problems. Why can’t we do something about that?”

The disease model didn’t really look at drinking as a behavior or as a habit. The big shift was to try to move it from strictly genetic into habits. “Smoking is a habit. It’s not a disease in itself, but it causes diseases.”
VY: That is changing, that field.
GM: It’s gradually changing. When I got into the field, people were saying, “Stay out.”

I Like to Drink

RA: There are some addictions that are considered controversial, like sex addiction. From your perspective, is it the object of the person's desire that is addictive, or is it the relationship between the person and what they're going after that's addictive?
GM: The new DSM-IV revisions have been including other kinds of addictive behaviors, like gambling, sexual addictions, shopaholism, things like that. From a cognitive behavioral perspective, there are a lot of similarities. There’s a lot of craving, whether it’s sex or gambling. There are differences in terms of the effects, of course, but I see there being lots of common issues.

One of the biggest things is the problem of immediate gratification. We call it the pig problem. “I want to hit the jackpot. I want to have a sexual experience. I want to get drunk.” All these kinds of things are very similar in terms of the neuroscience of what’s going on.

So I’m totally open to talking about addictive behaviors as including ones that don’t involve drug or alcohol use.
VY: You've been doing this for a few decades now, and addictions has been a career-long interest for you. What are some things you've learned that have made you a better therapist?
GM: I think having these experiences myself. I like to drink. I have drinking problems in my family. I wouldn’t consider myself an alcoholic. Many people in the addiction treatment field are in recovery so they’re saying, “Don’t use at all.” I’m much more user-friendly to these people because I do it myself. I’m helping to teach them that there are better ways to do this.

Since I’ve been more of a Buddhist psychologist, I took the bodhisattva vow, which is to reduce suffering in people that have these kinds of problems. If I can relate to them and identify with them rather than saying, “I am abstinent and you’re using,” it works a lot better.
VY: Thanks for taking the time to meet with us.
GM: You’re welcome. It’s been a pleasure.

Stephanie Brown on Treating Addictions in Psychotherapy

Posted on by rezendevknowfully.com

What happens when people stop drinking?

Randall C. Wyatt: How did you first get into working with people with all different kinds of addictions?
Stephanie Brown: Oh my (laughs), you jump right into it. Okay (sighs). I got in because of my own personal experience with alcoholism and recovery. I come from a family with two alcoholic parents. So I was born and bred in a family of alcoholism and therefore extremely interested in the subject because of my own personal experience.
RW: What experience was that?
SB: I grew up thinking about my parents' alcoholism and worried about them. As a teenager and then as a young adult I got to live out my own addiction and eventually entered recovery. Then I really looked around and asked what's going to happen to me now that I've stopped drinking. I began asking research questions when I was in graduate school in the early 1970s and in my doctoral thesis I asked questions about what happens to the individual who stops drinking.

RW: What kinds of questions did you ask?
SB: I asked: What happens to the children of alcoholics? How do we understand their development? Living with addiction, growing up with addiction, what happens to their normal developmental tasks? What's the impact on them of growing up with addicted parents? What is it like to be psychologically addicted? And then finally, I asked, what's the process of recovery for the alcoholic family, the addicted family, the one in which the alcoholic parent stops drinking?

I entered my own recovery in 1971. I've been very interested in the developmental process that occurs for people once they stop drinking. I developed the Dynamic Model of Active Addiction and Recovery through my doctoral research, which was finished in 1977.
RW: We’ll get back to that in a minute. When you started looking at your own addiction, did that affect your relationship with your parents and their drinking?
SB: Yes, it did. My recovery certainly had an impact on my relationship with my family. It was perhaps the caliber of a seven-point earthquake! There was a breach in my relationship with my family from that point on. I entered my own recovery when my family was still drinking and both my parents were severe alcoholics. My brother was an alcoholic. He's not drinking any longer but both of my parents died drinking. Not quite true. My mother stopped drinking in 2000 when she was 86 years old.
RW: Did you tell them you were going to stop drinking?
SB: When I stopped drinking, I told them what I was doing. They were supportive of me, which was really quite wonderful, especially my father. I think he knew something intuitively and he couldn't articulate it consciously; he knew, even though he couldn't get it for himself.

But what I felt was this radical breach because alcoholism for me and my family was the glue of attachment. It was the umbilical cord for my relationships with all of my family and extended family members. I felt like an orphan and I was treated like one.
But what I felt was this radical breach because alcoholism for me and my family was the glue of attachment. It was the umbilical cord for my relationships with all of my family and extended family members. I felt like an orphan and I was treated like one. Nobody knew how to relate to me since I was no longer drinking; it was the currency of relationship exchange; everybody drank together. Emotionally I was still connected with my parents and cared deeply about them but the bond was severed through my choice to be abstinent. My father died suddenly when I had nine months of abstinence; it was a real trauma for me, the loss of my father.
RW: How difficult it must have been to stop in a system that reinforces drinking and doesn’t encourage stopping.
SB: There was never any acknowledgement in the family that anyone else had any problem with alcohol;
I entered a different reality when I recognized my own alcoholism. Then, my entire world and my reality, the way I looked at myself and others, changed.
I entered a different reality when I recognized my own alcoholism. Then, my entire world and my reality, the way I looked at myself and others, changed. Everything I've written about for all these years has a very central focus on reality and what is reality. In the actively addicted person and family, there is such a distortion about what's real.

The Addiction Accounting System

RW: What do you mean by distortion of reality?
SB: There's a distortion about what's real in relationship to drinking, and therefore everything else. The family needs to protect the drinking in order to be able to maintain and sustain it. So when I stepped out of my family and determined that I was an alcoholic, I entered a different reality and have lived in a different reality for 36 years, in the sense that I could love my parents, I always did, but not share their world anymore. I needed to make that breach in order to survive and progress with my own development and my recovery.
Victor Yalom: You said that by implicitly supporting your abstinence your father had some awareness that his drinking and the family’s drinking was a problem.
Stephanie Brown: I did conclude that. It was never verbalized. I could indeed feel the connection with him and feel the support and later he encouraged me to seek support, to seek help and to stay close to my sobriety support networks.
VY: I think that’s often something that’s confusing to most therapists who don’t come from a background of addiction – that there’s a different reality for alcoholics. Like your father who had some awareness that he had a problem yet did not change.
SB: Correct. That's correct.
VY: So it’s not an either/or situation in the addicted person’s mind.
SB: Oh, that's right. Actually, for years I've taught the concept of "doubling" where you live with two different realities. Doubling is different than denial where you block out one part of reality. Here you live with opposing realities. "I have a problem with alcohol and I don't have a problem with alcohol. I'm fine living with both those identities and realities." And that's what makes working, living, and relating to people who are addicts or alcoholics crazy-making! It's crazy-making because the alcoholic is simultaneously saying,
"Yeah, I probably drink too much, but I'm not out of control and I don't have a problem with drinking."
"Yeah, I probably drink too much, but I'm not out of control and I don't have a problem with drinking."
RW: It seems like there’s a tendency of alcoholics and drug addicts to say, “Well, I have somewhat of a problem, I can handle it, and I’m not an addict since others are worse than me,” and there usually is somebody worse.
SB: Right. I think of it as an accounting system. Every alcoholic has a definition of what it would mean for me to think, "I am an alcoholic."
RW: For example?
SB: For example, an alcoholic is somebody who drinks before five o'clock in the afternoon; many people have that definition to this day. Well, I don't drink before five so therefore I'm not an alcoholic. There are others who say, "Well you know, an addict is somebody who gets admitted to the psych ward; I've never been admitted to the psych ward, I'm perfectly sane so I'm not an addict!"
RW: “I drink beer but I don’t drink hard stuff.” Or, “I drink wine only.”
SB: Exactly! Yet almost every single person on the planet of a certain age knows what an alcoholic or an addict is. Every year I teach elementary age kids and eighth graders and I say,
"What's an addict?" All the kids' hands go up and they say, "You've lost control, and you can't stop." They know what craving is, everybody knows what's an alcoholic and it's "not what I do."
"What's an addict?" All the kids' hands go up and they say, "You've lost control, and you can't stop." They know what craving is, everybody knows what's an alcoholic and it's "not what I do."
RW: What else do the kids say? Sometimes kids speak the truth in simplest terms.
SB: Yes, the kids say, "You can't stop, you've lost control, you've got to do it over and over again." I ask them, "Who here has had a craving?" All the hands go up. "I crave Coke (the soda) and chocolate." I ask them, "What does craving feel like?" and they say, "It hurts." I say, "Is craving painful?" "Yes! It hurts physically because you've got to have it."
RW: And even though you know the alcohol and the drug is messing up your life, ruining your relationships, and hurting your job, you keep doing it.
SB: Correct. You keep doing it. What is, is! You really don't want to do it but you have to do it and you tell yourself that you like it. You tell yourself that you're choosing to drink, that it tastes good, that you love it, that the drugs help you. You tell yourself that it makes you funnier, wittier, sexier, more charming; they keep you going. You keep reminding yourself and telling yourself that you don't have a problem, that you can stop any time, when the reality is that you can't. That's what addiction is.
RW: It’s really not as complicated as we often make it out to be.
SB: And everybody knows it and everybody will tell you why it doesn't apply to them.
In my technical definition, the addicted person denies that he or she has any problem with a substance and then explains why he or she needs it in a way that allows them to maintain the use. You deny, you explain, so that you can maintain using, so you don't have to stop.
In my technical definition, the addicted person denies that he or she has any problem with a substance and then explains why he or she needs it in a way that allows them to maintain the use. You deny, you explain, so that you can maintain using, so you don't have to stop.
VY: So for you, that’s the hallmark of an addict, the loss of control.
SB: The hallmark is the loss of control.

Binge Drinking

VY: So how do you think about situations like college binge drinking? I don’t know the figures but a high percentage of college students go through a period where they exhibit a loss of control of their drinking and it causes problems for them. So by that definition, these people are addicts and alcoholics and yet most of them don’t become chronic alcoholics.
SB: What we're seeing is epidemic numbers of college kids and younger who are out of control.
In many young people, there is no inner mechanism in place to moderate their drinking and they're ending up with the most severe advanced consequences of alcoholism at a young age.
In many young people, there is no inner mechanism in place to moderate their drinking and they're ending up with the most severe advanced consequences of alcoholism at a young age. Not only are they binge drinking but there's so many other drugs on board that tend to create more severe consequences sooner.
VY: But not for all of them.
SB: Not for all of them, correct. So what happened? Why is that?
VY: Well, I guess that is my challenge to you. It seems that in some recovery circles the idea is once someone is out of control with drinking he is an alcoholic. And once an alcoholic, always an alcoholic. But I’ve certainly worked with a lot of patients who report to me that in their college, or younger days, they were drinking excessively. They were binge drinking and they may have frequently drank to an excess in their early 20’s, but they’ve grown up in their late 30’s and 40’s and aren’t alcoholics.
SB: Yep, I've seen it too and I think there are a number of ways to explain it. Some people merge with what others are doing around them, into the social norm like eating, smoking, drinking or drugging and the situation triggers them.
RW: It’s a social thing for some people.
SB: Yes, but it's as if it's a social merger phenomenon. There are patterns, in relationships you watch this, where a partner will say "Well, I never used to drink at all but my partner was drinking and I started drinking to keep up. It was going to be drinking with him or get a divorce." So that person becomes addicted out of a need to join with the other. Yet, when the one partner dies of addiction and the survivor stops drinking then that points to it being more social. But just the same they were drinking or using addictively that entire time.
RW: It seems that there is a gradation from a person who is a social drinker, a problem drinker and then an alcoholic. Some kind of 1 to 10 scale. Do you have any thought processes like that?
SB: By the time they are seeking help for it, by the time it's been identified as a problem they are way over the line. Are there gradations? Yes, there are beginning, middle, and late advanced stages and phases and signs and symptoms of alcoholism that have been identified for 75 years. Yet, a lot of what I might be able to identify as a problem with alcohol, most people would say, "That's not a problem, everybody drinks that way."
RW: What is an okay way in your mind for people to drink alcohol that would not be considered alcoholism?
SB: For me, well again, alcoholism is the loss of control so I am not so much into the exact number of drinks as a determining factor. Rather, I look for the signs of people becoming out of control. I look at what people's relationship is to alcohol. Alcoholism is a key primary attachment to the drug, more important than any other attachment the individual has.

If you watch a person's focus on alcohol they turn psychologically, emotionally towards the attachment to the substance. People talk about alcohol as their best friend; people take it to bed with them. They have their primary relationship with their bottle, with their Jack Daniels, with their Jim Beam. Alcohol becomes the central organizing principle for the alcoholic and then it operates in the same way for the family or friends. Getting it, having it, drinking together, sharing it, stopping it, starting it again, and so on.
RW: It’s a way of life.
SB: It's a way of life.
Sometimes you can recognize alcoholics by watching their attachment to the glass in hand. Then it's possible to identify alcoholism before some of the more obvious signs become visible.
Sometimes you can recognize alcoholics by watching their attachment to the glass in hand. Then it's possible to identify alcoholism before some of the more obvious signs become visible.
VY: We live in the Bay Area where wine is such a big thing. How would you distinguish between someone who really loves and appreciates wine from an alcoholic? There are certainly a lot of wine connoisseurs who enjoy wine that are not alcoholics.
SB: That I believe is true, it may be true. What I find, actually, is that sometimes being a wine connoisseur is a wonderful cover for alcoholism. Many people who love wine and have wine collections come in to my office. Do I say that if you're a wine connoisseur, it means you are an alcoholic? Absolutely not! But there is the strong attachment to the alcohol and organizing your life around tasting and having alcohol and socializing with alcohol. So you're going to have a much higher likelihood statistically of alcoholism in a group that is organized around it.

Addiction to Drugs, Prescription Meds, Food, Gambling

RW: I want to ask a few questions about drugs. In what way are drug addictions similar? Take speed for example, or heroin. Do you think of yourself as treating all addictions in a similar manner, or do your ideas just apply to alcoholism?
SB: Everything, absolutely everything. All addictions. In fact, I don't use the word alcoholism as much anymore as I do addiction.
Addiction is substances, behaviors, and relationships. The addiction is behavioral addiction, the loss of control in relation to substances of all kinds.
Addiction is substances, behaviors, and relationships. The addiction is behavioral addiction, the loss of control in relation to substances of all kinds. Legal, which is alcohol or prescription medications; illegal, which are many others such as speed, cocaine, heroine, pot. Legal and illegal drugs can be used together, increasing the dangers of overdose.

Prescription medication is both legal and illegal actually because you're supposed to have prescriptions for them but they are available illegally on the streets, over the internet, on school and college campuses. For many people, OxyContin and Vicodin have become drugs of choice. People are ending up in emergency rooms with dangerous overdoses.

Tobacco is an addictive substance. The behaviors: gambling, out of control sexual behaviors, specific kinds of sexual addictions to pornography and the internet are all kinds of loss of control.
RW: An excessive psychological attachment to these things is an addiction, which is like a relationship. And it becomes bigger than the other things in life.
SB: Correct. It becomes bigger than the other things. You've got to have it. You can't stop. It's repetitive, it becomes a compulsion that drives it and you repeatedly seek the substance or the behavior, the gambling, the pornography, the sexuality, the food and eating behavior that gets out of control. At a certain point addiction becomes almost normative in the culture.

Sentenced Treatments and Addiction Outcomes

RW: Recently California passed a law that said people with drug and alcohol related legal problems can, should, or must undergo treatment before going to jail; do you think that has an impact for the good?
SB: I love intervention at the judicial system level that first focuses on treatment. I think that's excellent, it's outstanding. As far as I know, the programs have been very successful in these first five to eight years. You especially see success when the Justices are on board and have educated themselves. Some of the Justices in Santa Clara County are phenomenal. They're intervening right there with the addicted person and the family and children.
VY: How are the outcomes looking?
SB: In the beginnings of this it would be its own revolving door and the treatment was not particularly informed or sophisticated. It's gotten better. The longer the treatment is the better the outcomes. You're seeing very good outcomes now.
RW: You used the word “sentenced” to treatment but usually in psychologically based therapy we think if the person is involuntary and isn’t motivated, it’s not going to be very useful. How does that affect treatment of substance abusers?
SB: I used to take a stance against anybody being sentenced to anything, but now I'm a convert. I have been converted.
RW: You have had a conversion experience!
SB: Well, because our culture is out of control. They're coming in every door, usually massive numbers of young people coming in through juvenile justice. But so many more people are having criminal contact first because of illegal drug use or the damage and consequences of use. I see that for many people it's the sentencing that speaks the loudest, that carries the biggest stick. If the consequences and the sentences are severe enough, this gives people time in treatment to find their own motivation, and many people do.

More people are coming in my door who are out of control. They're dominated by impulse disorders and they're not functional anymore. Their lives are falling apart and they are trying to get their lives back.
VY: What’s an example of that?
SB: Their everyday lives are so dominated by needing to drink, needing to use drugs, where the compulsion is overwhelming to them 24 hours a day. They may still be working in good jobs but they are careening to the bottom much faster than we've ever seen before. They've got stimulants on board, depressants on board. They have so many medications and they are often prescribed. They're using alcohol and they're out of control. I see people in their 40's, 50's who have up to eight medications and they're drinking. They've got medications to wake them up in the morning, medications to go to sleep at night.
These are people who have lost any sense of who they are apart from their addiction. They have lost any kind of a center of their self that is not connected to their compulsive and impulsive driven behavior.
These are people who have lost any sense of who they are apart from their addiction. They have lost any kind of a center of their self that is not connected to their compulsive and impulsive driven behavior. It's a phenomenon.

What do therapists who don’t specialize in addictions need to know?

VY: As a psychologist and a therapist who doesn’t specialize in addictions, just hearing that sounds overwhelming. What are some basic things that therapists who don’t specialize in addictions need to know?
SB: Well to start, I don't use the term "problem drinking." People often use the term "problem drinking" as the biggest defense. Many therapists who are undereducated about addiction actually collude with their clients. If therapists take a drinking history they will often conclude, "Oh, this person is a social drinker. This person doesn't have a problem with alcohol, this person drinks like I do, maybe a bit too much and needs to cut back some."
There's a long-standing joke in the therapist community that the definition of an alcoholic is someone who drinks more than I do.
There's a long-standing joke in the therapist community that the definition of an alcoholic is someone who drinks more than I do.

The therapist says, "Okay, how much do you drink?" and the person says, "I have a couple of glasses of wine a day." I always put down a "couple of glasses of wine" in quotes because that is everybody's favorite quote.
RW: Or everybody says “a couple of beers,” “couple of martinis” and so on. But one has to distinguish between those that really have a couple and those that have more.
SB: Certainly, but let me give an example. A patient comes in and says, "I have a couple of glasses of wine." I ask, "When do you have that?", and they say "With dinner, I have it to wind down, to relax." The typical therapist makes a note on alcohol, "no problem."

Does the therapist say, "Tell me some more about how you drink, tell me some more about these couple of glasses of wine, how do you think about it, what's been your history with alcohol" and begin to use that first question as a starting point for a much more in-depth assessment of attachment? What you want to find is not just how much the person drinks but what their relationship to alcohol is.
VY: Can you say more about what you mean by attachment to alcohol and how one can discern this in therapy?
SB: Very few therapists will understand that you're looking for the attachment rather than the amounts. What you're going to be listening for are the ways in which the individual focuses on alcohol day to day. Let me play it out here in a conversation so you can see what I mean.

A client comes in one day saying "Jeez, I'm late today" or "I was late to work."

Therapist: Well what made you late?
Client: Oh, I overslept.
Therapist: How come you did that? Is that typical for you?
Client: Well I had a big weekend.
Therapist: Oh, what happened?
Client: Well we partied.

But don't stop there!

Therapist: Tell me more, what do you mean partied?

And later, Therapist: Give me a sense of a day in your life.

Now watch as the addicted client will eventually begin to include alcohol or drugs or whatever their addiction is in their daily activities and way of thinking. People who have an attachment to alcohol tell stories to friends and families about their lives that include alcohol, hoping to see if anyone wants to join them.
VY: Okay, let’s say the person comes in and it’s clear that they have a problem with drinking. There’s enough data that it can’t be hidden. What are some other common mistakes or deficiencies therapists have when moving forward in treatment with addicted clients?
SB: Therapists tend to think, "If I recognize that this person has a problem with alcohol or other substances, that this person is alcoholic then I have to do something about it and I don't have a clue what I as a therapist can do." Most therapists come to me for consultation asking, "How do I make this person stop drinking?" That's the wrong question, the codependence stance, and it makes the therapist want to turn away from the addiction or person. What if you say to this person, "I think you have a problem with alcohol. What do you think about that?" and the person may say, "Well, I'm not coming back here anymore, thank you very much."

So we'll collude together here, agreeing that there is no problem with alcohol and we'll have a very fine psychotherapy and avoid the tough issues.
VY: Again, say we have gotten past this point. The therapist is savvy enough to see that the patient does have a problem but does not have a great deal of training in addictions. Obviously you can’t do an in-depth training in this interview, but what are some pointers that you can share?
SB: On a similar thread, therapists have mistaken beliefs about what the role of the therapist is, the responsibility, or the terrible word, the obligation. And most of the errors occur around that mistaken view that that you're supposed to do something about it once it's diagnosed. You do want to have an awareness about the addiction in the room together. And yet you don't have to make the person do anything.

The therapist's job is to keep the focus on the reality of the addiction and what the person wants to do about it.
The therapist's job is to keep the focus on the reality of the addiction and what the person wants to do about it. How your patient feels about it, sees it, what that person wants to do about it, what is most frightening. Often times a person's family history comes in at this point: "Well, I hate to see myself as an alcoholic, I don't want to be one, and I don't want to go to AA. I'm not going to stop drinking because that would make me like my father."
VY: Okay, then how does the therapist work with this type of client? What do we do when resistance to change inevitably comes up?
SB: In good intensive psychodynamic therapy mode you notice resistance at many levels. The client may resist the identity of being an alcoholic: "Okay I know I have a problem with alcohol, I should stop, I don't want to. I don't want to be an alcoholic." People show resistance to action: "I know I am an alcoholic, but I'm not ready to do anything about it." Then there is the resistance to changing behavior: "Okay, I'm an alcoholic but I'll take care of it myself, and I don't really want to stop, I want to be able to drink now and then." Getting through these resistances one by one to get to abstinence is a process that may take some time in psychotherapy. Now, there are many people, particularly in San Francisco, at the heart of Harm Reduction School who think about this differently.

Brown on Harm Reduction Recovery Models

RW: What are your thoughts on Harm Reduction models of recovery?
SB: Harm Reduction is great; it is an intervention that works in the active addiction stage. My model is the Developmental Model of Addiction and Recovery – that is recovery based on abstinence and abstinence only. So my theories are based on people who belong to AA, who have total abstinence and total sobriety, who are not drinking or using anything, so it's a much longer developmental process. Harm Reduction is an intervention in active addiction that is helping people who are continuing to use. It's a completely different theory, a completely different treatment and it can also be incredibly useful and helpful to people.
RW: Can you describe, basically, what Harm Reduction is, since it has become much more popular than in past years in the recovery world?
SB: Harm Reduction is intervening in a way to help people, with all kinds of drugs including alcohol, but it started with methadone maintenance. It aims to help somebody change the level of substance use but not become totally abstinent. You're going to substitute something else that will reduce the harm and enable people to function, to perhaps get off the street, to be in better communities. Many people who have been in Harm Reduction have also used 12-steps, which is inconsistent—they are contradictory, but that is the real world people live in. They are using less of their substances. In a sense, they are reducing the harm; they're reducing the self-destruction, the harm to themselves and others. It's really a terrific help on the way for many people to full abstinence and a 12-step recovery, yet for many people it's not on the way.
RW: It’s where they’re going to stay.
SB: It's where they're going to stay but it's helpful and how could I be against it? I absolutely am an advocate for all of the different kinds of recovery. Now, my definition of recovery includes the 12-step recovery model.
RW: It’s my sense that Harm Reduction could be of use to help some people become social drinkers or less self-destructive drinkers. But for others with chronic alcoholism, in my experience, the Harm Reduction route is just tantamount to pouring the drink for them. It seems like for some people that are in the chronic stage of addiction, their health is affected and their brains are deteriorating, or their life is just so messed up – it just seems like a cycle. It seems like part of that game of addiction.
SB: Well, that's the dilemma for the helper and the person seeking help for anybody at any time in any model.
RW: Good point. That can apply for Harm Reduction or your abstinence model in the real world of people with complex lives.
SB: Absolutely. And the helper at any point should be asking "Am I helping, am I contributing?" In my model, the psychotherapist is always asking, "Am I colluding with the denial here, should I be more challenging?" The therapist is always in the position of not knowing.
We don't get to know whether our particular point of view and our particular intervention is going to be beneficial or not for the person in front of us. We just don't get to know in the moment.
We don't get to know whether our particular point of view and our particular intervention is going to be beneficial or not for the person in front of us. We just don't get to know in the moment. So we have to be maintaining integrity by being willing to ask, "For this particular person, am I helping or harming them?"

The Developmental Model of Addiction and Recovery

RW: Well said, let’s go to AA now. For you, psychotherapy with an addict seems to naturally involve a recommendation for the patient to be in an AA or a 12-step group of some kind. Can you explain the rationale for that?
SB: My developmental model is a theory of how people change, what happens to people who belong to a 12-step program.
VY: It would be very helpful to briefly state what your developmental model is.
SB:
The Developmental Model of Addiction and Recovery is a model of transformational change. It's a model of radical change.
The Developmental Model of Addiction and Recovery is a model of transformational change. It's a model of radical change. The individual comes to recognize "I have lost control," and that recognition is at a deep level. We can call it an emotional level; we can call it a psychological level of knowledge, an epistemological sense of knowing the self or spiritual experience. The person comes to know, "I have lost control" and simultaneously if all goes well, the person says, "I'm an alcoholic."

If those experiences happen, the person may very well be moved via that experience into asking for help. It is the asking for help, reaching outside of the self, no longer saying "I've got to get control of myself" or "I've got to learn how to drink."
The person says, "I can't stop, I need help." It is in the actions of accepting loss of control – I can't stop – and then reaching out for help that the change process begins.
The person says, "I can't stop, I need help." It is in the actions of accepting loss of control – I can't stop – and then reaching out for help that the change process begins.
RW: Is this what people refer to as hitting bottom, or surrendering somehow?
SB: That's the first experience – to hit bottom, to surrender, and to reach outside the self. So people seek help, they go to 12-steps. They then shift their object attachment from alcohol to a 12-step group, or to a treatment or mission- based center. They shift to whatever substitute will take the place so that they are still taking in, they still have an attachment. They begin to go to meetings; they'll get a sponsor. They begin to take in the new object replacement for the substance.
VY: Why do you think this shift is so crucial to recovery?
SB: It is important so that you are not asked to give up your substance for nothing. The recognition is that you need a substitute attachment, so you get it. When you reach out for help, you're going to reach out for a new object that represents recovery. It represents abstinence in the 12-step model and so the process of transformational change is under way with the shifted object attachment and the substitute new behaviors. What are the new behaviors? Going to the meetings, reaching for the phone, being in action to substitute something that represents recovery.
RW: How much does it matter what that attachment is?
SB: I now see a lot of people going into treatment for addiction who are taking so many legal medications. They're making their object attachment to the medication, instead of, "I have hit bottom. I am attaching to recovery." These people are struggling in AA and NA. They're sitting at meetings thinking about, "How's my level of medications, should I up my antidepressants?" They're talking all about the new object attachment to their medications.
RW: Well, I recall that in years past, many in psychology and psychiatry and the AA world would say, “Keep psychiatric drug use in recovery to a minimum and only when necessary,” and it used to be discouraged and used only in particular cases with caution. Now only-when-necessary seems to be almost-all-the-time.
SB: The addiction treatment centers by and large have been wary of medications from day one. And often when somebody enters a formal treatment center, mostly private, they will be taken off as many of the psychiatric medications as possible. Most patients entering any addiction treatments are already on multiple medications. They've been prescribed by psychiatrists, by internists, by family physicians. That's what we see as normative.
RW: Why do they do take patients off their medications in treatment centers?
SB: Because they want to see who's there in the person. They want to start with removal of all mind-altering substances. Then the person will be taken through a medical detoxification, which may or may not include some detoxification medicines. And they go through the assessment process and may be prescribed medication at that point if indicated.

Understanding Therapist Impatience and Frustration in Addiction Work

RW: Most therapists get very impatient with a patient who goes back and forth between quitting alcohol or drugs and using again. How does the psychodynamic, existential or CBT therapist with some training in addictions deal with the impatience and frustration inherent in this work?
SB: I think that, as you said, many therapists get impatient with addictions. This is one of the reasons why therapists would often rather not see people with addictions. Therapists think they have to do something once they diagnose it, but also therapists many times really look down on addicts for their lack of self control or they may simply not understand what is happening.

Therapists, then, may tend to get impatient because they really do sense that the client is shining them on, and it's true that many clients will be in denial and distort and deceive. The therapist needs to look at what is going on in the patient and not act it out in a countertransferential way.
A therapist will get mad at the addicted patient, confront the patient, yell at the patient; tell them to stop doing it, which is an over-reactive countertransferenece response.
A therapist will get mad at the addicted patient, confront the patient, yell at the patient; tell them to stop doing it, which is an over-reactive countertransferenece response.
VY: What should they say instead?
SB: I might say something like, "I can hear your deception. Can you hear it? I hear it day after day. You want me to agree with you. I don't agree. You want me to say, " Yeah there's no problem here.' I hear the problem. You've got so much invested in not seeing what you're doing. You're drinking yourself to death. I'm wondering, what's in the way of your getting this? That you're going to want to do something?" And then I might say, "Here we are looking at it and you don't want to see it; what's it going to take for you to want to deal with it?"
RW: Where is the therapeutic alliance in all of this? How does that play into the work?
SB: This is a therapist who is confronting within a therapeutic alliance. "I am not going to collude with you. I am going to confront you." I'm not going to bash your head in and scream at you, but I am going to challenge you. I'm going to tell you that I'm impatient. I sit here and I hear you being so self-destructive and I hear your deception, your distortion and you want me to go along with it? Can't do it! Not getting on board with it. I'm worried about you. What's it going to take?"

And that's the way in which the therapist maintains the alliance while working with someone who is conning and deceptive and manipulative. If the patient keeps coming to you, that person wants help. Let me add, there are many people who are not conning, deceptive or manipulative. Many people want help and can't see clearly what is wrong and what to do. They need support for seeing clearly and guidance in the next steps. They have to feel safe enough to recognize their loss of control.
RW: So the therapist is confronting by coming alongside the patient by giving the message that “I am for you, yet I’m not going to go along with your self-destructive behaviors and self deceptions and say nothing.”
SB: Exactly. With many people you're dealing with resistance and defense. And the defenses are the thinking distortions, the self-deceptions. The way a person with an addiction says, "I don't have a problem with alcohol, I can stop any time I want, I don't drink before five, and I'm perfectly fine. My problem is my wife, my problem is you, and every time I come in here and every week you want to talk about alcohol. You're my problem."

And I say, "Yep, I'm your problem alright because I'm going to keep talking about alcohol. I think it's your main attachment. I think it's the center of your life. You don't want to see it that way, but I hear it and I see it."

Psychotherapy, AA and Spirituality

RW: Do you think psychotherapy alone can help the person get out of a strong addiction to drugs or alcohol? Or do you think they need a group, AA, or something like that to get attached to?
SB: Therapy alone can help a person make a determination.
Psychotherapy is in fact terrific because people will come through the therapy office door sooner than they will go to AA or go to treatment.
Psychotherapy is in fact terrific because people will come through the therapy office door sooner than they will go to AA or go to treatment. All therapists should be able to help that person coming in the door recognize, "I am an alcoholic. I've got a problem with alcohol." Therapy alone can be incredibly helpful to the person making the decision to stop. I recommend to all people that they use AA, Al-Anon, NA, all the 12-step programs.
RW: What do you value so much about AA?
SB: AA has something that psychotherapy doesn't have. It has the most fundamental shared experience of equality. I think there is nothing like AA for an experience of an equal and shared humanity.
RW: So more in real or everyday terms, what does that mean?
SB: When you come to AA, you find you are an alcoholic amongst other alcoholics, addicts. There is no hierarchy, there's no governing force, there's nothing. You walk in the door and you belong, you walk out the door, you come back. You can attend meetings worldwide. And within that framework, equality is absolutely astounding.

In psychotherapy it's an unequal structure. It's not equal, we're not peers. In any kind of help-seeking framework with the exception of peer counseling there is still the helper and the "helpee", as I call it. Within AA, every single person sitting together is both a helper and a helpee at the same time. You get to experience yourself as being the dependent person needing the help of others and the one who shares your experiences to help others in the same moment.
RW: Now, a lot of people object to AA and they have their reasons; “It’s too public, it’s too religious,” and so forth. But also it seems a certain group of people don’t do well in a group setting like AA where it’s so uncomfortable for them; not just resistance, but they say it doesn’t meet with their mindset, their worldview, or their way of relating in the world. What about those people who it doesn’t seem to work with?
SB: Well, you know what, you said it like most people who are skeptics say it. I hear researchers say, "Well, AA or 12-steps doesn't work for everyone." I want to say, "Wait a minute, it is possible." AA doesn't see itself as trying to be a fit for everyone. It's not AA's job. AA sits there waiting for people to find a way to let AA work for them and it does in fact. It's everywhere in the world. AA is working who can become engaged in allowing it to work for them. So I ask people to reframe the way they think about it. What's in the way for this particular person? What is the individual's resistance to AA?

I tell patients that people are not standing in line waiting to get into AA. No one wants to go to AA. So then how is it that millions of people have found a way to let AA work for them? It's in the individual; it's not in AA.
RW: I would agree with you, I could say much the same thing to that resistance. But at the same time, I think certain people who go to AA hear other people’s stories and it triggers their wanting to drink. If they don’t go, then it doesn’t trigger it. The therapist would be wise to notice these triggers.
SB: I let people know that there are all kinds of meetings and some that just work on steps where no stories are told. I teach people how to use AA. I suggest that everyone has difficulties. I suggest that they go to a meeting, sit by the door and if they can't tolerate it, they should leave. But then come back. It's like desensitization. Come back again and leave when you can't tolerate it. It's recommended that you come in early and stay after because that's how people start to talk to one another. But if you can't do that, don't do it. And as you're sitting in a meeting, listen for what fits for you. Pick out the people that you liked, what they said and don't take anything else. And then go to many different meetings and you're going to sit in a meeting and say, "Well this one feels right," or "I really like that person but I didn't like that meeting."
RW: Some people object to the question of a higher power, some people object because there is a God. And some people say the opposite, that they feel others demean God by saying it’s a door handle, you must have heard that one, but I doubt many people see their God as a door handle.
SB: Yeah, I have heard that one. Let me give you the theoretical view about transformational change and why and how it works. Let me step back a bit to make this clearer.

I define spirituality as dependence; that's what it is to me within the framework of thinking about addiction and recovery. Spirituality is dependence, and the god of the addict is the alcohol. The dependence, the spirituality, is invested in the attachment to alcohol. When that person comes in to AA, the dependency, the attachment is changed to the meeting, to a new sponsor, to the people of AA, to the ideas espoused in AA, to the books and readings. The dependence is transferred to a new object representing recovery.
RW: How does a person’s sense of attachment and spirituality change over the course of their recovery in this model?
SB: Dependency is gratified; spirituality is gratified for you right away. Over the course of the stages of recovery the longer people are in recovery, they move in their development through concrete object representation into much more abstract substituted object relationships. Through working with the steps, perhaps through being in psychotherapy, a lot of people in recovery begin to develop a more abstract concept about what a higher power will mean for them.

So that dependency moves over time, developmentally from concrete object representation to abstract concepts of God. And it's a developmental process.
AA based recovery is organized by the individual at a pace that works for them. All under the control of the alcoholic in recovery. There is no defined God, there is no set scripture, and there is no theology in AA.
AA based recovery is organized by the individual at a pace that works for them. All under the control of the alcoholic in recovery. There is no defined God, there is no set scripture, and there is no theology in AA. There is nothing but the concept of God as the person defines God. It is paradoxically the most control and autonomy possible for most people in the world.
RW: “Academic psychology has believed in the power of self, the power of the ego, the will.”
SB: In terms of the profession of psychology and psychotherapy and spirituality, Freud said religion is an illusion, Skinner and Ellis said belief in a higher power is a neurosis and irrational, and humanists basically said that humans are God in full control of their own destiny, though there is some room for a person to freely choose to believe or not believe. Basically, the three major psychologies have traditionally been highly critical of spirituality and criticize any traditional semblance of a higher power in general.
RW: In terms of the profession of psychology and psychotherapy and spirituality, Freud said religion is an illusion, Skinner and Ellis said belief in a higher power is a neurosis and irrational, and humanists basically said that humans are God in full control of their own destiny, though there is some room for a person to freely choose to believe or not believe. Basically, the three major psychologies have traditionally been highly critical of spirituality and criticize any traditional semblance of a higher power in general.
SB: Absolutely, psychology as a mental health discipline has been more anti-AA than any discipline across the board for the last 50 years. Psychology in the past has worked very hard to disprove and to challenge AA. Nowadays many more of the academic people would like to understand AA and bridge the gap. In my opinion, academic psychology has believed in the power of elevating the ego, elevating the self, the human, to be the ultimate source of power.
RW: Beyond other people, community, and family, let alone spirituality or a God.
SB: Academic psychology has believed in the power of self, the power of the ego, the will. And therefore any human being ought to be able to control their own drinking and that's what academic psychology and psychotherapy have supported.
I look at the addict as the ultimate leveler for all of humanity because addiction says we have limits. Psychology basically has said that human beings don't have any limits. The God of academic psychology is the self.
I look at the addict as the ultimate leveler for all of humanity because addiction says we have limits. Psychology basically has said that human beings don't have any limits. The God of academic psychology is the self.
RW: “You are the captain of your own ship. Chart your own course. Do it yourself with will power.” It is as if therapists and psychologists become do-it-yourself motivational speakers.
SB: That's right! And we will teach you how. So there is a terrific egotism that has grown up within psychology that believes in the elevation of the self and ego as the ultimate change agent.

Integrating Addiction and Psychotherapeutic Work

VY: Well one nice thing about your work and an important one is that you try to bridge the gap between psychologists, psychotherapists and the 12-step world. And you have offered some ideas about what therapists can learn from the addictions world. In that regard, I think it’s also fair to say that a lot of addiction counselors in treatment programs have not taken advantage of the teachings and skills that psychotherapists have developed. What do you think addictions counselors can learn from psychotherapists?
SB: I've said for 35 years, I have a foot in both fields; one foot in psychology as a mental health professional and one foot in the addiction community as an addiction professional. So I live and breathe both and I have tried to be the interpreter back and forth because I believe the fields have been antagonistic when they didn't need to be. For many years in the 70's and 80's the addiction counselors had no training at all and were simply using their own experiences to become counselors. There was a lot of animosity in the 70's and 80's against psychotherapy.

They were right, in many cases, but that has changed dramatically. Addictions counselors, starting in the 80's and 90's, now have to have academic training. There are addictions certification programs that are very solid and based on a lot of mental health training as well as addiction training. They're becoming psychologists and marriage family therapists. So, we're getting a larger and larger group of people who wear both hats.

Yet, where psychology has been willing to say, "Why don't the addiction counselors want to know more about psychology, we'll teach them" – would psychotherapists go to a residency and treatment program for a week to learn about recovery? No, I don't think so.
RW: I think another element to this issue is how therapists view the differences in working with addicted and non-addicted populations. For example, take a neurotic person, or person who is not addicted to anything but is anxious or depressed. They don’t have impulse problems, but they may be overly self-critical and self-conscious and act punitively against themselves, or they may worry too much or be worn down by life. Therapists are used to seeing these types of clients. Whereas the addict is often a person who has impulse control problems and is acting out into the world, is blaming, can be deceptive, destructive and so forth. So for the therapist this is a different world. One requires soothing, comfort and explanation, insight, perhaps transference work, and the other may need confrontation, boundaries, reality work, and direction. They are two very different ways of doing therapy.
SB: That is so well put! That's just a gem the way you stated it. Really nicely put. (I would venture to tell you that you're seeing less and less of that neurotic that you just described coming into anybody's door since the culture is so out of control.) The way you describe it is so useful, that therapists are used to seeing people who are more self-destructive but the addict is acting out externally. Being addicted is the highway of destruction.
RW: The typical psychotherapist knows something about addictions but tends to think that working with people with addictions is very different.
SB: You know what, it's really not that much different. Therapists may think so. If the person has an addiction and some capacity for self-reflection, I'm going to be working in the psychotherapeutic frame and I can work very similar to how you might work with the anxious or depressed person. The same reflection, what it means, how you think about it, what's going on for you; it's the same frame.

With every single person, no matter how out of control they are, I'm sitting they're saying, "What's that about, what do you think is going on?" I never leave the frame of listening and trying to make sense of what is happening in the room. Now, with a particular person who walks in my door, there may be more issues of containment and boundary setting. You have to come back to the addiction if they don't. You have to wonder how it serves them. I may say, "You're drinking the way you're drinking because it's helpful to you in some way. What does it do for you? How does it function for you?"

It's a very similar type of frame to most therapies, but often the countertransference, as I noted, is quite different in the therapist.

The Most Rewarding Part of Addictions Work

RW: We have time for a few more questions only since we know you must get to a dinner. In your experience, do people coming in with addictions to alcohol or drugs get better?
SB: Through these doorways, yes it works. My job and any therapist's job is to recognize when it's not working, when the person is so out of control that they can no longer utilize psychotherapy, which requires the capacity to reflect. Sometimes people are so impulse disordered that there's no reflection, then you can't use psychotherapy anymore, certainly not without more support and structure. Then you have to up for a more intensive level of treatment very quickly. You have to have interventions like treatments programs or through the justice system.
RW: What’s the most rewarding thing to you about working with people who are addicted?
SB: (big sigh, long pause)
RW: Did I shock you with the question?
SB: Yeah (tears up).
RW: Well, I’d like to know.
SB: I'll tell you in a sec. I'm not sure if I have just one thing.
RW: One or more if you like.
SB: This is just the most profound gift for me to work with somebody who wants to change so deeply and is willing to take the steps despite the difficulties. I am moved over and over and over again that anybody ever gets in the door (tears up again). I believe anyone coming in this door wants help and it's my job to not get in their way. So the best gift to me is when they find in themselves the desire and the willingness to take the next step even though they don't know where it's going.

It's all steps of faith and trust and not knowing. You just don't know every single step you take where you're going. I tell you, these people take these steps and are willing. People get well and they trust in me and I always feel moved by that trust. And staying with them to hold the space where they can find it in themselves is just profound.
RW: That is truly profound, and reminds me of what you called the radical transformation.
VY: We wish we could go into more depth into all of your works, but another day, thank you so much for sharing your work and yourself with us.
SB: This has been an amazing conversation, thank you.
VY: Thank you. You have tremendous passion.
SB: I always say I'm the luckiest person in the world.
RW: I can see why.

Transforming the Wounds of Racism: An Autoethnographic Exploration and Implications for Psychotherapy

Posted on by rezendevknowfully.com

A young boy splatters my painstakingly finished painting, taunting me to go back to where I had come from. I accuse his ancestors of plundering my nation: "Look what your people have done to my people." (Saira, eight years old)

The stories of colonialism that my father had told me suddenly came to life and I felt bold and proud as I looked to my teacher for further confirmation. She remained silent as the other children laughed at me. I found myself shrinking away in that moment of humiliation. I think about that experience quite often and I imagine what might have happened if my teacher had affirmed my words. Especially, now that the cultural landscape has changed and I see white women with henna tattoos, and Indian fashions, designs and music everywhere I look. It is curious that what was once denigrated is now accepted and desired. This is both inexplicable and inspiring to me.

My brother and I are in the garden gathering brittle autumn leaves for the fire, savouring the sweet evening air in our lungs. Two white teenage boys peer over our back fence and throw stones and litter at us alongside racist jibes. I feel they are treating us like animals in a zoo; I feel fear rise in my belly but feel compelled not to show it. My father appears and gently asks them if they would like to join us. I feel bewildered and betrayed by his reaction. The boys sit beside us and floating embers settle in our hair as we eat baked potatoes plucked from the fire. We make reluctant and inquisitive eye contact with one another and as the fear dissipates, I can see they want to be a part of this simple activity of togetherness. (Saira, ten years old)

Racism was a part of the backdrop of our lives. It was not discussed and I was given no guidance on how to make sense of it. It is only now, many years later, that I recognise the gift my father gave me that night: he showed me that I could acknowledge and stay with the disquiet and dread of racism and that I could find ways other than fear and dread to be with it. During my dissertation research on this topic, I held onto these memories like a talisman.

Authoenthnography as a way to understand racism and trauma

I wanted to become a therapist who was not bound up in the rigidity of her boundaries, so that I could begin to stretch and push the boundaries of otherness and sameness. As a psychotherapist, I wondered how racism is explored or avoided in psychotherapeutic work. I saw that racism can often enter psychotherapy in a disguised form as it is difficult to express due to the fearful and defended nature of racism. This results in racist trauma being overlooked and minimised, which can be oppressive and silencing in itself. In this work, I have tried to illustrate how stories were told and understood in order to facilitate empathy with groups that are sometimes neglected and marginalized.

Autoethnography¹ has developed from ethnography, anthropology, sociology, and cultural studies and serves to challenge traditional historical relations of power. Autoethnography is different from autobiography in that it describes the conflict of culture and identifies how one becomes othered within a cultural and social context. This method of research allows us to remake and understand subjective experience from creative and analytic first-person accounts of people's lives. It makes use of interviews, dialogues, self-conscious writing, and other creative forms to facilitate an expanded awareness for the author and audience. Autoethnography is the study of the awareness of the self (auto) within culture (ethnic); it is a way to connect the personal with the cultural.

I have tried to create a more heartfelt space where wounds can be subjectively named and understood. I wished to engage in new ways of thinking about how therapists' life events can change practice and awareness for themselves and the field. The illuminated relationship between the researcher and the researched is made transparent in this work as it took me to places, internally and geographically, that I had never been…

This is not just a story about racist trauma—it is a story about longing, loss, and discovery. It weaves back and forth in time, and as a result, it is written in both the present and past tense.

Straddling two worlds

As a child, I was a keen observer, soaking up the living memories of my parents' homeland, of dance, song, and food that produced solidarity and unity. As a group, they felt alienated and displaced from all that was familiar. My aunts told and retold stories; this helped them maintain their cultural voices, and this collectively made them a powerful force in my life. The men were on the edges of these stories and were largely uninvited to storytelling as it was felt they were both "too important" to be burdened with the tales and too "weak" to bear the sorrow associated with them.

I straddled both the ancestral and modern worlds, and I was given the gift of being able to find myself within these stories. Despite the fact that these mementoes of my heritage were somewhat fragmentary, I was still left fascinated by them. My aunts came from a culture that emphasised togetherness and unity. In their dependent and highly emotional world, they sought kinship and solace with each other. This was in part because they became increasingly ambivalent about their splintered place and identity in the world due to the forces of migration.

As I grew older, I started to embody a western culture, and it became apparent that cultural differences were intolerable to my family, as any individuation was an annihilation of the collective. I felt increasingly like an outsider, both inside and outside the home. I was inexplicable and perplexing to them, particularly when at 13, I dyed my hair pink and daubed hand-painted feminist slogans over my clothes. My family clucked with pride when I responded to their coaxing by wearing a sari for a family event. I felt such sensual pleasure in the swaths of beautiful pea-green silk that I did not want to lose its "magical qualities." In turn, [I refused to take the sari off, ruining their hopes by experimentally skateboarding in it.] I was continually challenging their ideas of what a traditional Asian woman should represent and grappling with the contradictions and paradoxes inherent in this process.

Myself as witness

How do I trace the roots of my estrangement and disconnection from these men who were central to my life, to my heart? I have waited for a long time for them to come home—psychically, physically, and emotionally. I have always wished that they would be returned to me, like at the end of fairy tales. Through my research process, I felt like I was making the decision that I could not passively wait for their return any longer. Whilst being immersed in this research, I felt a strong need to reclaim my deeply yearned for yet seemingly irrecoverable lost connections.

I did not know for certain when I started this research that my father, uncle, and brother were lost to me by racism and its effects. These experiences were unheard and unspoken in my rambling and rather tribal family. I believe the speaking of racism evoked fear and shame that might further tear at the fraying fabric of my family. Racism, for me, was bound in the wrappings of humiliation and silence. It was so tightly swathed, I only heard it as a fearful whisper. I have subsequently discovered these traumatic racist experiences ranged from vague, insidious and intangible experiences to shattering, violent acts.

As I felt the oscillations of these unspoken narratives inside myself, it led me to create musings, fantasies and assumptions about the subject matter. I sat at my desk, feeling bewildered and paralyzed at the horror and pain of the family narratives, and despair at their disconnection from me, wondering how it was possible to get closer to the subjectivity of such experience. This possibility felt charged, potent and unfathomable. I deliberated and wondered repeatedly if I should speak with my family about the research—would it harm them further? What are the ethics of taking this into the public world? What would the research do to our relationship? Issues around confidentiality buzzed around my head and my colleagues and I talked about them incessantly.

I questioned the possibility further: What will my peers make of me? Would I be derided and discounted by the "therapeutic community" for revealing not just myself, but also my family? Would I be able to produce something evocative, powerful, and representative of our experiences? Is this the story of significant men in my family or my story of loss? Can I find the words for trauma that sits beyond language to describe what cannot be spoken? The question remained with no easy answers.

My father's scars

My father was disillusioned and troubled when he fled to England to practice law in the 1940s. His best friend and neighbour during the partition in India stabbed him. He only mentioned the scar on his stomach in passing when I pressed him to let me into his interior world. He believed Britishness embodied fairness and justice as he had been successfully inculcated into the colonial belief that he and his kind were inferior. He beamed with pride at redefining himself as a "brown English man" and negated his "primitive and corrupt" cultural origins with vitriol, never wishing to return.

In remaking his identity, he resolutely refused to believe that his struggle to secure a job as a barrister was due even in part to his colour. He was a dishwasher, a porter, and a lift attendant—all the while, trying to maintain his respectability and pride. He would arrive to work with his bowler hat and impeccable pinstriped suit each day. then change into his overalls to start his shift. He was inaccessible to us as he strove to carve out a place in the world, and his identity was embedded in his need to work hard and achieve. His failure critically punctured his self-esteem.

The eventual disaffection and disillusionment with his idealization of Britishness seemed inevitable. However, its impact was made worse because he was unable to digest the racism he endured. He saw the hostile, racist persecutory world making him feel small and powerless. He seemed to see racism and oppression everywhere. These crises led him to alcoholism and admission to a psychiatric hospital for depression.  “He sat on his prayer mat and cried like a child as he spoke of England like a lover that had abandoned and disappointed him.” He turned away from it as he had his homeland.

In turning away from Britishness and all it represented, my father turned further away from me. Had I come to embody what he could not bear? I could not find any comfort in taking my distress to him and he could not bear the weight of his child's woundedness. The effects of his trauma marked our family, and although we did not live through his trauma, we did live within its confines.

It is frustrating to feel the familiar inaccessibility in his death as I did in his life. What would he have discounted or embraced in these descriptions? My father was a harsh man who shielded himself from the world and eventually lived a hermit-like existence, but he gave me the best of his capacity to love. All I can name is what I know: that every day I spent with him he was unpredictable and closed off, living in a desolate land. I could not find him anywhere. And now I cannot quite find him in the untranslatability of these narrative descriptions.

While my own father was busily being a perfectionistic workaholic, my mother was whimsical, dreamy, furiously caught up in her culture and clan. My uncle represented a world of calm and safety. How do I adequately describe how much I loved my uncle? I have always found great comfort in looking at his face, the familiarity I felt in watching him smoking his cigarettes—his recognizable outline meant that my life slotted into place.

My uncle leaves… the unanswered questions

I now realize he was a mere young man at the time, but seemed then to offer a very different quality of attachment. I remember him driving a maroon Mini with a squeaky leather interior that I would slide around on. He would sit with me on the stairs when I had undigested bad dreams about cowboys and Native American Indians and would speak softly of worlds full of magic and kindness until I felt safe enough to fall asleep again. He taught me to gently put the needle on the record and wait breathlessly until the song would start in the smoky recesses of his room. He would capture my crinkle-nosed smile in his photographs and I felt rewarded with his attention and gaze.

His leaving to emigrate to Canada when I was six felt like an unanswered question and for a long time I wondered why he left, and yearned for him to come back. His absence was profoundly painful to me as a child. I wondered if my mother had sent him away or if his new wife asked him to leave. As I grew up, a part of me imagined it was due to racism. Not that I knew much of his experiences with racism, but I overheard fragments of conversations of how he "hated England," and that "terrible things happened to him." It led me to conclude that racism was the only conceivable reason he left. Why did I assume it was racism? Had I made something up? Perhaps it helped me believe as a young child that something terrible took him away rather than facing the fact that he had chosen to leave me.

"It felt embarrassing to talk about the humiliating aspect of it, your sense of masculinity is wounded and injured, you feel that you should have taken a stand but you did not feel able to as a man." (Saira's uncle)

Early on, I asked my uncle what he thought about my research—was it meaningful to him? He said he had many stories of racism and its associated trauma that he had not spoken of, yet they were still alive inside of him. I instantly felt relieved that these experiences were real and not entirely the result of my imagination, although I feared I would not be able to hear and bear these stories. How might the telling of these narratives benefit him? At this stage, I felt lost in the littering of these broken attachments and in a turbulent state of anxiety and confusion, although later I recognised that this was a place of important struggle and sorrow.

Unwelcome in the new world

My uncle arrived in England from Pakistan in the 1950s at 10 years of age accompanied by a throng of older and younger sisters with kilos of sweating Indian sweets wrapped painstakingly in silver foil. However, the family was ill-prepared for the cold as they arrived in the dead of winter in only their thin cotton shirts. All 10 children started their life in Britain in an asbestos-ridden caravan, confused and unsettled after coming from a place of wealth and comfort. Later, the family moved into one room with little space, and their material conditions worsened. They lacked any comprehension of the new culture or landscape they faced. This migratory journey remained an untold story because it evoked shame of their struggle to find a place of belonging and the emotional and literal poverty of their experience. The exodus was supposed to be rich with offers of new possibilities, the enticement laced with the promise that they would be rewarded if they worked hard and managed to forget the familiar sun, and the textures and colours of home.

My uncle was pleased to find that people were initially curious about him, his history, and difference. Later, this changed and it seems humiliation and shame coloured much of his experience as a young man. He remembers standing at a bus stop racially abused whilst those in the polite orderly English queue silently looked on, witnessing him being scorned and disrespected for simply existing. He felt the disdain when he was spat at for embodying and personifying otherness, his palpable foreignness and physicality making him a threat to himself. The skin he represented made him exquisitely visible and invisible.

"Look what the cat's dragged in" was his greeting on the first day at his new job; he was 16. He felt cheated; where was the promise of a better life? Then he was threatened with a knife in a public bathroom where a gang of men in a savage racist attack set upon him, dousing him in their anger and fury. He felt unwelcome in the new world.

He walked around in shame and isolation, wondering how he could make a mark on the world when his voice had fallen away. Humiliation tearing at his throat, he swallowed the contempt and its effects began to house themselves inside of him.

Connection and disconnection

My brother on my Uncle's shoulder, me in the park… I chew on the long feathery grasses that sway in the wind, shimmer in the sunlight; I thought I was eating the sunshine. (Saira as a young child)

These are the happiest times I can remember. I felt connected to the world and myself when I was with my uncle. My adoring view of him was in part due to the way he invited us into other worlds of music, song, and nature. I was full in the stillness.

He and the white English woman that he loved and hoped to marry sat together in the ordinary familiarity of the train carriage. He loved train journeys, watching familiar landmarks appearing and disappearing from view as the train juddered out of the station. This defining journey turned bad for him as a heavily built white man sitting across from him began to mumble and then roar at how "his kind" had defiled his partner's virginity, taking something from him—from all white men. “The pain of past racist violent blows he had experienced did not compare in their intensity to this expression of violent hate that was coming at him now.” The torrid racist expletives bounced around the walls of the carriage, exposing and belittling him.

The emotional impact was initially shock; he described feeling a numbing paralysis in his body. As they decided to escape and disembark at the next station, he wondered how his body would support him, when it felt so insubstantial. Time slowed to a stop as he felt the flush of disgrace and helplessness overcome him. The other travellers in the carriage looked on, some with interest, others with avoidance; did they find themselves agreeing with this man's hate? Is that why they did not protest? Or was it fear that this contempt would be directed towards them?

He felt his girlfriend was defiled in her association with him; it was as if she was contaminated by the colour of his skin into something more sexualised and objectifiable. They never spoke of this incident, but it was the beginning of the end of their relationship, because in that long moment, amongst all of the shame and emasculation, was her witness of his diminishment.

When he moved to Canada, he left me too, but more poignantly he left himself. The racism that had infused his world disconnected him from himself and those around him, such an unspoken cruelty when contact and connection was the gift he gave me.

"Racism was not the main reason I left"

I journeyed to Canada to meet my uncle, 30 years after he left England. To engage in a dialogue about something so personal and painful leaves me anxious and curious. I am researcher/niece/ psychologist/ therapist/child all at the same time. These multiple selves offer a dynamic shifting of one into the other, each adding a new voice. He is a stranger to me now, but there is a strong memory of childhood intimacy that attracts me to him. Yet I feel shy. I want to hide away in my researcher/therapist self to anchor me, but this dialogue requires courage to be intimate and honest. I wonder if I am capable.

We sit in his basement with a scratchy blanket on our knees, as I anxiously wonder if my new tape recorder will work. At the same time I wonder how my husband is, as I left him making polite conversation with my uncle's wife upstairs. Are they wondering what we are discussing downstairs?

He says slowly, "No, racism was not the main reason I left." My long-held assumption momentarily floats away. What does this mean now? He tells me he came to Canada to begin again: a new life, a new job. He does not want to be perceived as someone who cowardly ran away. Did my questions about his leaving further diminish him? It seems to me that he needs me to clearly understand his reasons for leaving. I feel a need to honour this, while still I wrestle with what this means for me and for him. Self-doubts creep in… Were my assumptions off base? Was I too committed to these assumptions before hearing his version of events?

Acts of reinvention

It is as if racism had blighted his life for many years; the hurt and the vividness of the memories live on and become ignited as he speaks of it after 40 years. He says he felt like a victim, which left him terribly alone and split him apart. He says, "I don't know if white people could relate, or appreciate the racist experience. You have to be on the receiving end of it. Only our people could understand this shared experience, to know what it is like to be spat at, to be hated. I do not know if they would be able to really make a connection. You have to live through something like that."

He became vigilant and wary of whiteness. It has been 30 years since he experienced such overt racism, yet he still sees all white people as outsiders. I can psychologically understand this but emotionally it does not fit for me. I cannot feel this way because our narrative experiences are different.

His own racism remains unacknowledged. He does not see it as racism, but rather as a wish to preserve the integrity of his culture, with the lines drawn in a colour-coded way. Whiteness must be kept out or at best treated with a large dose of scepticism. I try to wonder with him whether his racism precedes or emerges from his own racist trauma. How does whiteness threaten his cultural and religious beliefs? I try to get into a dialogue about this, but he is rigid and fixed in his ideas just like those who hated him for what his skin represented.

It seems these feelings became more pronounced when he began to reinvent himself. This reinvention of himself, he believes, was born from the isolation and emasculation of the racism that penetrated him. He needed to recreate and recapture a self by finding value in his culture after coming from such a place of shame. He found a resilience and strength that came from his community and culture, mainly from his spiritual connection to music. He made these connections to preserve a self that had been discounted. “He felt embraced and accepted in this place… a place to stand with his hurts.”

The more toxic effects of the shame and indignity went away, yet he remains mistrustful of anyone who tries to get too close. This mistrust includes me and I realise there is an awkwardness that sits between my uncle and me that does not go away.

I felt deeply hurt and angry by the racism he described, but more so that he had nowhere to take his woundedness. I begin to wonder if I in some way represented the England he had to leave behind. How do I speak of my anger at being left and feeling forgotten? I try to talk about this but the words do not come out right and they stick in my throat.

He reads the narrative that I have taken from him and insists he has nothing to add or

change. "It's an accurate description and it's interesting to know of you through doing this," he says. He sees my expression of sadness at his leaving England as his failure; I cannot quite find the words to explain how much he meant to me that made his leaving so agonizing for me. Is it too late? It is as if he has already turned away. His world seems to exist of outsiders and insiders. I think I begin to exist somewhere in between for him, as the residual effects of this trauma mean that he remains far away.

As we are preparing to leave, he shows me photographs he took of me as a child from an album as closed as his past. He tells me that his happiest memory of those times was the crinkly smile that I saved for him as a child. Despite this, I feel heartbroken all over again.

Healing some wounds

As I listened to and then transcribed my uncle's story, he maintained power over his words as he revised and amended his descriptions. I wrote the narrative piece that he had editorial control over. He was able to acknowledge his loss of self due to racist trauma, but the recognition of his resilience and his sense of agency was made real by the act of linking events to his act of self-expression. I noted that his resilience was activated to survive adversity. He expressed this resilience in the form of forgiveness: "I have survived so much and learned that forgiving others (racists) has helped me have another chance at life."

I grappled with the need to see my uncle as a survivor and hero, and preserve my continued idealisation of him. I can see how he continues to bear terrible scars that I naively believed could be bridged by this research. Yet, what was healing was making sense of these previously unspoken trauma experiences that we were no longer compelled to exclude, a behaviour that was normalised within the family. These narratives brought validation and the possibility of new attachments. However, this narrative was not entirely healing with orderly resolutions.²

My uncle's residence abroad meant the dialogue we were able to share in person was concentrated over a week and followed up by telephone and email contact. I felt disappointed that I did not have more time with my uncle in the research, but is this not how I began, lamenting the loss of my time with him? He seemed unengaged after a time and denied wishing to change the material in the text after the first few revisions. He said there were no negative effects of the research on him, but I wondered if he felt discomfort at our increased contact. I have now not heard from him for a number of months and suspect he wishes to re-establish some distance and renewed separateness. I have honoured this for now and so I continue to feel his absence every day.

In writing about racism and trauma, I am writing about my life, family, and community, which is quite charged. I have become careful not to contribute to the splitting in the world of racism, or in believing that the racist monster prevails and that those of colour are helpless and victimised. I have found that by opening up categories and sitting in between these splits and divides that I can see the situation more clearly. I cannot simply hate the racist, because I have loved those who have voiced racisms of their own, like my father and my uncle. Similarly, I have been touched by this work, wrestled with forgiveness and humanness, and appreciated that the resulting embodied awareness may go a long way in creating connections across divisions.

Coming home again

A gang of boys corners me and threats me, but they become half-hearted and change their minds because they are unsure of where to locate my colour or ethnicity. I feel initially relieved and then angry that they do not recognise me for what I am. I try to call them back. (Saira, eight years old)

I go to Mexico, Mexicans claim me; in Italy they speak to me in Italian that I grope to understand; in Paris, the police stop me and assume I am an Arab; and in India, they do not know where I am from. A client comments to me about how much she despises Pakistanis and how relieved she is that she can speak openly of her contempt, as it becomes clear that she thinks I am from Jordan. (Saira as an adult)

My family would joke and say, "You may as well be white." This was not just a form of shadism, but to emphasize my difference from them. My skin colour is not easily identifiable, yet I am kept othered and my difference is imagined. All of this points to the idea that skin colour is unimportant in itself, but the projections, internalisations and consequences it carries do matter. We cannot ignore or minimise this impact as sometimes it becomes a matter of life and death, be it physical or psychological.

I internalized the shame of my cultural difference, and my Asianness seemed inexplicably both a bad and a good thing. I have struggled with the shame that glued my insides together and writing this has been a battle of sticking and unsticking those glued parts. This work gave shame a place to speak from. I have wrestled with finding my voice and I recognise that the humiliation and guilt at being a witness to racist trauma has been like an eighteenth-century corset encasing me and defining my shape. I have reframed this narrative as one of transgenerational and intergenerational racist trauma. I intimately feel the terrible loss and abandonment by these significant males. Now I am less bound up and defined by this trauma. I am not sure, though, where I go from here.

The effects of these traumatic absences have left emptiness in my life, and acknowledging the pain and sadness of missing these men who were once vitally present has changed something between us. I am able to love them just as they are in the hope that there will be moments when they will be returned to me, which happens every now and then with a smile a word, a gesture, or a memory.

I am changed in other ways, as well. This is best illustrated with an ordinary encounter of getting into the same taxi with four years in between.

Sometime during the beginning of my research, I slide into the taxi as I register the racist hate in the taxi driver's eyes; he glares at me. I am surprised and uncomfortable as I inhabit his confined territory, his taxi seems like a closed-off, taut world of hate and revulsion that leaves me unsettled and unsafe but reminds me that this work means I have to be able to dwell in this place. (Saira)

Four years later, my research is in the final revision process, and another taxi ride…

After spending an afternoon revising my research, I am cooking rice with my mother… the aromatic Indian herbs and spices envelop me… nice to be home again. I feel a mixture of self-consciousness and pride about my project. I get into the waiting taxi preoccupied with these very thoughts. I look up and slowly recognise it is the same taxi driver. He recoils from me, as if I am able to pollute and invade his being. I look at him steadily, filled with curiousity. Where does this contempt come from? What does it do to him? I experience what I can only describe as warmth, expansiveness and loving compassion for him. I happily beam at him because he is representative of the journey that has reshaped me. I do not experience his hate as a terrible wound. I feel no fear. I am not shamed. In that moment and for a long while afterwards, I feel completely free. (Saira)

The implications of autoethnography for psychotherapy

I think about autoethnography interacting with psychotherapy not necessarily as an approach in itself or a distinct form of therapy, but as a set of attitudes towards self and other which can facilitate the creation of an internal bridging and connection. This means that rather than having a set of explicit tools to work with racist trauma, therapists are required to develop and seek out heightened processes of awareness and embodied ways of being. This awareness migrates into practice in a more accessible and less defensive way by helping the therapist engage in highly sensitive and profoundly painful areas of the client's story through varied subjectivities and reframing processes.

The interaction between autoethnography and psychotherapy is also a journey of personal discovery and a self-reflective process. This work became a therapeutically available surface that I could work on inside and outside my own therapy, transforming the relationships with those in research that I love.

For myself as a therapist, “this journey has enhanced my capacity to be more accessible and present in my client work”. I also feel more able to generate conversations and dialogue about racist trauma and the racial experiences of my clients in the therapeutic relationship. Through disentangling racism within myself and others, I find there is an encouragement of an alternative state of awareness that is more self-reflective, and less guilt-ridden and avoidant. This process produced a deepening of understanding and processing of self-generated and self-defined identities that was empowering as it undermined racist and racial stereotypes and helped me to encourage my clients to do so. I think I am better able to seek out such disconnections and attempt to create a worked for connectivity where I can be less constrained in my language and thinking, having developed the capacity to be more available to enter into the webs of racialised discourse in my clinical work and in myself.

Autoethnography can be a profoundly useful way of accessing memories of complex racially traumatic experiences that may be implicit and built upon sediments and layers of racial slights and injuries that contribute to psychological grief and social maladjustment. Skin colour plays an important part in structuring of the world, and the colour coding of the self and psyche. As therapists, we are called to work through this for ourselves and our clients; otherwise it will reappear as the therapist's unexamined countertransference and will perplex and confound the therapy.³ The engagement with otherness takes us out of what is seemingly familiar and encourages us to travel to alternative places within ourselves. It is from this position that I wish to dissolve detachment, isolation and marginalisation to create connections and healing.

Refuse to wither and die

These stories have found a home inside of me, and I realised that I have been writing this story for the whole of my life. Now that it is committed to paper, I can see how it has helped me to love.

Notes

2 Franks, A. At the Will of the Body: Reflections on Illness (Boston, Houghton Mifflin, 1991).

3 Dalal, F. Transcultural perspectives on psychodynamic therapy; Addressing external and internal realities in The Journal of Group Analysis, 30 (London, Sage publications 1997) p. 203.

4 Bronson, P. Why do I love these people: The families we come from and the families we form (London Harvill Secker, 2005).

For further information on authoethnography:

Ellis, C. The ethnographic 1, a methodological novel about autoethnography ( NY, Altamira, 2004).

Gottschalk, S., Banks, A. and Banks, S.T. Fiction and Social Science, By Ice or Fire, (Walnut Creek, Altamira, 1998).