Creative counselors are always looking for ways to lessen the anxiety of their patients so as to allow freer expression of difficult personal and clinical material. Keven Duffy intuited a technique that she has found useful in that it allows her clients to construe their relationships with problematic substances and behaviors in a way that helps some connect with and explore difficult material. She argues that changing the language and the framework created a way for her patients to deal with difficult issues with less “euphoric recall” than they might otherwise have had to confront. Please share your thoughts and ideas in the comments section after the article…Richard Juman
Jen, who is in her mid-twenties, came to see me after a serious suicide attempt after a decade of heroin abuse (up to 15 bags daily). One of her first thoughts after her suicide attempt was, “I’m such a failure, I can’t even kill myself properly.” When we looked into her addiction to opiates, she recognized that she needed to stop using. However, her glorification of the drug remained. As we fleshed it out, something inside me as a clinician started to feel that her descriptions of the drug’s impact on her life sounded more like a human relationship than one with a substance. “I felt whole”…“It was always there”… “I could always count on it…” One day, my supervisor, Dr. Nicholas Samstag, suggested that I ask her if heroin could text, would it?
After working in drug rehabilitation for several years, I’ve discerned that current treatment protocols have little place for symbolism. That is not to suggest that today’s best practices don’t help to alleviate the behaviors. Patients are able to identify relapse triggers, develop coping skills to handle these triggers, attend the myriad of support groups available, build a sober network and benefit from a host of other very effective tools that I use regularly in my practice.
However, I have begun to see that if the patient has the ability to symbolize, to work within a frame that is abstract and personify their substance of choice by giving it a name, its own attributes and then exploring the “relationship,” deeper work can be done: insights into object relations, attachment and traumas that might not have been revealed otherwise.
Often in recovery, the underlying feelings of shame and guilt attached to a substance use disorder are difficult to approach, as the patient has obviated those feelings in his or her newfound sobriety.
As a result of these insights, I have begun to literally personify the addictive relationship with some of my patients in order to lessen these feelings of shame and guilt associated with the often-negative consequences of the addictive behavior—the collateral damage, so to speak. Personification allows for a dialogue to emerge where patients are in control of how they want to portray the behavior and role of their substance in a way that creates a safe environment. Thus, I work with the client to create a human persona around their substance of choice and in doing so, the patient can look at their own negative behavior with a bit of distance or some objectivity. With this approach, most people with addictive behaviors will agree that “it” (the substance) is a relationship, not just a drug.
So I asked Jen, “If heroin were a person, who would it be?” “David,” she replies, without hesitation. “Not Dave?” “No, David.” She describes him as an Adonis, perfect in every way. So we begin and start to flesh out the relationship.
She shares that it was love at first sight. She fell hard and fast. “David” was always there for her (yes, at the beginning he was a big texter). She readily admits that she had never been treated so well. He was her ideal of perfection: he gave her warmth, and a feeling of connectedness—something she never felt before. He was there when she needed him. They were inseparable. When he went away, she longed for him, and his promises to return were always kept. At this point, David was there to give her pleasure, not mop up her pain.
Before David (heroin), she shared that her relationships with men left her feeling vulnerable. She was somewhat shy, and had always suffered from low self-esteem while dealing with an eating disorder since age fourteen. Most men couldn’t see beyond her quirky eating habits and her need to have sex in the dark. “David” was different. With David, she had confidence, energy, and the hunger she was tormented by with her eating disorder was all but gone.
After several months, the relationship changed. Jen needed David more than he needed her. However, her love never wavered. In fact, it increased. In relationship terms, she had to admit that she wasn’t jealous when she found him in the presence of other women and men with the same attachment to this seeming Svengali. At one point she said, “Nothing mattered but David. I just needed what only he could give me.” This is the point of her full-blown addiction when heroin took over her life.
It was about then that “David” started asking her for money she didn’t have. She very shamefully admitted that she got David the money however she could. This I knew because she originally presented with a larceny conviction. She had stolen money to be with David. He possessed her soul. Interestingly, in our sessions, her affect remained flat in her recounting of her ever-increasing obsession with David and his demands.
Then there came the day when David, using Jen’s love for him, asked her to sleep with other men in order to get money for him. She did it without question. She ended up sleeping with several drug dealers to give David money until one day she just couldn’t anymore. And that’s they day that she drove her car away, homeless and on a mission to kill herself. Little by little, she had been putting aside a bag of heroin at a time until she thought she had saved up enough to overdose.
When she woke up, alive, she recognized that she could no longer do David’s bidding and needed to begin the process of moving away from him. In our sessions, Jen fully embraced this personification, as it allowed her to frame her relationship with heroin in a way that more easily brought forth insights, recognizing that she slept with dealers for him (heroin), stole money for him (heroin) and tried to die because of him (heroin). To date, she hasn’t been with “David” for over two years.
We don’t always talk about heroin as “David.” But the work that we did allowed her to move away from any hint of “euphoric recall.” It allowed her to work out how the drug seduced her into dire circumstances, to see what she did to obtain it, in a frame that was unfamiliar and yet familiar. In creating David, Jen was able to symbolize aspects of other relationships in her life that have manifested themselves into her psyche.
Through our conversations about David, we were also able to look at how her rejection by other men left her with low self-esteem and how David did not. She saw that her life was filled with conditional love. Her mission was to find that long-desired acceptance. “David” asked no questions, but in the end, she just was very needy, she had to be with him all the time, or she would be very, very sick. That’s what heroin does. You go into withdrawal and use more, you use too much and die, or you get clean.
I have used this personification technique with other clients for whom substance use is not the problem. Heather, in her mid-thirties, has an eating disorder. She has recently rejected her 20-year relationship with “Luigi,” her in-therapy personification of vomiting. Luigi and Heather have lived side by side for most of her life. She describes Luigi as a balding, out of shape “dude” who unapologetically wears stained wife-beaters and talks with his mouth full. Despite her revulsion for his physical appearance, she invariably listened when he whispered into her ear the sweet nothings that only a binge/purge food-disordered person loves to hear: “Those crackers might as well have been a Big Mac,” “Why did you eat five carrots instead of just four?”
When we discussed the idea of saying goodbye to “Luigi,” the extreme anxiety it created for Heather heightened to the point of having to drop the line of inquiry. She needed him. Luigi was an integral part of “The Plan,” which is how we couched her overall eating disorder. In examining the nature of what relationship Luigi could represent from her past, she struggled. It was only when I asked what his voice sounded like that the insight came. It was her mother who, Heather began to realize, struggled with her own eating disorder, albeit one of yo-yo and fad diets.
The discovery that Luigi was a facet of her relationship with her mother opened up a new line of inquiry about that relationship, and helped her look at her mother as an individual, not just as her “mother.” In doing so, she was able to recognize that listening to “Luigi” was a continued version of obeying her mother. Even at 36 years old, she needed to please her mother, or risk losing her affection. We concluded that her mother was a narcissist, one of the “I’m the most special victim” types. Heather saw that her mother used her as a surrogate designed to meet the perfection her mother could not meet herself.
Once these concepts were integrated into our therapeutic dialogue, “Luigi” began to take the back burner in our sessions. Weeks, then months would go by with no vomiting. Luigi was on the way out. He still popped up now and then in times of stress, but Heather has banished Luigi along with her dysfunctional relationship with her mother. In fact, once she recognized the Luigi/mother connection, she became more assertive in what she would accept from her mother’s behavior; the more she gained control of her feelings and of how she interacted with her mother, the less Luigi was around.
What did “David” and “Luigi” do for my patients? They tried to destroy them, but in our work together they became part of the cure. In the analysis of these relationships, we were able to make a reference to past negative influences that perhaps led them into problematic behaviors and then look at them though a different lens, one that is more familiar and easy to discuss. For Heather, “I broke up with David because I was sick of his bad behavior,” is much less anxiety provoking than, “I was a heroin addict for ten years, sold my body, stole money, and lived in a trap house to be closer to copping dope.” The former allows the patient to flesh out all aspects of what the addictive relationship did to and for them in a non-threatening manner. While the shame and guilt of the latter statement is always in the room and is addressed throughout treatment, it doesn’t impinge on the exploration of the reasons the addiction began, the impact of object relations or the underlying emotions/feelings that were being numbed by the addiction when the client personifies their addiction.
Addictions are relationships that exist in lives that can take precedence over human ones. It’s interesting to look at just how these addiction relationships play a “role” in a patient’s life. Once I asked a group of 10 people in an Intensive Outpatient Group if, when active, they would choose their drug over their partner? All of the honest ones said yes.
Keven Duffy is an LMSW working at a Manhattan-based Outpatient Substance Abuse and Mental Health Agency. She graduated NYU in 2014 and is currently in post-graduate study at the William Alanson White Institute focusing on Eating Disorders, Compulsions and Addictions.