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

Distorted Beliefs about Addiction

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

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

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

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

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

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

The Emotional Work of Recovery

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

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