Image

With unusual honesty, Barry Lessin highlights the indefatigable work and refusal to submit to multiple frustrations and setbacks that is often required in psychotherapy with challenging clients. He describes how his long-term work with a woman whose history of severe sexual, physical and emotional abuse leads to hope and healing in a larger family context. This piece lays bare the complexity of mental health and addiction work, allowing old wounds to heal in a atmosphere of trust and safety. -Richard Juman

Each person's path to recovery is unique. Because the possible combinations of life history, pre-morbid personality and substance misuse are practically infinite, my work as an addiction psychologist is always intriguing. I look forward to each opportunity to share in my clients' journeys.

By the time people see me for consultations about their substance-using family member, they're generally feeling pretty battered and bruised. Feelings of helplessness and hopelessness often aren't far behind, but the very fact that they present for treatment indicates that they still believe that change can happen. That part of the family psyche is my ally in treatment, the aspect that I rely on to help me move the family forward to a new way of responding to problems and, ultimately, a new paradigm for operating as a system. Here, things get even more complicated when a woman's history of trauma and substance misuse have multiple ramifications on the work that we do as a family around her son's substance misuse.

Transforming trauma

"Nancy" (details of her treatment and experience are modified to protect privacy) initially entered treatment because her increased drinking was beginning to affect both her own self-esteem and her family relationships. As we explored the reasons for her drinking, it became apparent that symptoms of post traumatic stress disorder (PTSD), stemming from a childhood of severe abuse, were becoming more debilitating. She also was worried about the fact that her pattern of compulsive sexual behavior was becoming increasingly more dangerous.

A feeling of dread settled over me when she shared about her sexual compulsivity. For me, the easy part about being an addictions therapist is treating the substance use, itself. And although working with a co-occurring mental health issue like PTSD will require me to pull my sleeves up and get my hands dirty, I relish these moments because this is where the greatest opportunity for change occurs and guiding this process is exciting. Sexual compulsivity and sex addiction add another layer of complexity, often requiring group and marital therapy in addition to individual therapy.

Nancy's basic sense of safety and trust in the world was shattered when as a young girl she was the victim of ongoing physical, sexual and emotional abuse. Although the details of the abuse were important for her healing from trauma in her own individual treatment, which has lasted for many years, what's essential here is to convey an understanding of how the trauma affected her, how she responded to it, and how the insights and coping skills she gained from her treatment contributed to managing present stressors more effectively.

Initially, Nancy saw her drinking problem as revolving around her social life and self confidence, saying "I can't have any fun going out unless I drink." She worked diligently to resolve her alcohol misuse problem, starting by reducing her drinking, and then eventually choosing abstinence. As she made progress cutting back on her drinking, though, her PTSD symptoms became more prominent and disruptive, frequently leaving her feeling "like I'm going crazy and need to numb myself out."

She eventually learned that she also used alcohol to manage her PTSD symptoms. Her treatment then focused on developing other strategies for managing her PTSD symptoms and she now drinks only on rare social occasions. Bolstered by her success in managing her drinking, she agreed to attend a specialized outpatient therapy group for sex addiction while continuing to work with me individually. The group provided important peer support, furthered her insight into the reasons for her self-destructive behaviors and facilitated healing from her childhood of trauma. Combined with our individual work, she learned to manage the triggers and urges that were associated with her harmful behaviors, and eventually was able to eliminate them.

Resilience and multigenerational family recovery

While continuing in individual psychotherapy with me, her youngest child's ("Rick") ongoing substance use problem became an ongoing major stressor for Nancy, her husband and their family. Now a young adult, Rick was born with a life-threatening medical condition that required 24/7 vigilance for the first 15 months of his life to monitor and prevent breathing stoppage. Later, Rick also had challenging mental health and learning issues as a young boy and a significant substance use disorder starting in adolescence. His heroin addiction has been a prominent issue for the past six years, so even as Nancy came to be able to appreciate the freedom of her own recovery, Rick's worsening addiction bogged her down. Although the entire family was impacted by Rick's addiction, for Nancy in particular, her son's addiction re-energized many of the issues that she struggled with in her own mental health and addiction recovery:
The fact that she had been the primary caregiver responsible for literally keeping Rick alive during the early years of his life created a unique bond and attachment that exists today. This attachment has, at times, made it very difficult to establish the emotional boundaries that she needed in order to be better able to provide support for her son's needs while maintaining her own mental health.
  • Her experience of tremendous guilt about her drinking as she parented Rick and his two older siblings, without receiving much in the way of emotional support from her husband.
  • Her own parenting, which occurred in the shadow of the abuse that she received from her own parents, always colored her experience of herself as a parent, contributing to uncertainty and low self-esteem. She saw herself, largely as a result of distorted beliefs, as we will see below, continuing the pattern of the abusive parenting from the previous generation.
  • Rick's frequent flirting with death, through his addiction and his own suicidal wishes, often triggered the feelings of depression, helplessness, hopelessness and suicidal ideation that are chronic issues for Nancy.
An essential component in my work with families is incorporating the CRAFT (Community Reinforcement and Family Training) approach. CRAFT is an evidence-based approach that uses non-confrontational methods to encourage loved ones to enter into treatment. A significant feature of this approach is that it helps family members embrace their existing strengths and resources, empowering them to improve their lives independently of the substance user.

In Nancy's situation, I had the luxury, so to speak, of already being highly aware of her emotional log-jams as well as her profound resources because of the work we were doing, and the progress she was making in her individual psychotherapy. As a barometer of her progress in managing her PTSD symptoms, while we initially had phone calls between sessions when she was overwhelmed by symptoms, she later was able to calm herself by listening to my voice-mail greeting, and eventually was able to settle herself down without additional assistance from me.

I was witness to her fierce determination to heal, and saw the results in our family sessions, in which her husband and children confirmed her nurturing presence in their lives and the strong, healthy relationships she maintains with them and her grandchildren. This shift was huge for Nancy because initially the guilt from her drinking while her children were young was debilitating, leading her to say things like, "I'm a horrible parent, I'm damaging my kids just like my parents damaged me." Her perceptual distortions and feelings of powerlessness from her PTSD, led her to often comment, "I live in fear that I'm going to abuse my kids in the same way." These fears eventually dissipated when her grandchildren were born, allowing her to authentically connect with her nurturing instincts and say, "I see how much my kids love me and I'm proud of that."


Comment: Study shows psychotherapy useful in treating post-traumatic stress disorder in early stages


I must admit my patience can get sorely tested when I work with clients with severe trauma. Their skills, strength and resilience are laid out to me like a gift to work with, but their trauma defenses prevent them from acknowledging or accessing it until the healing process moves forward. I frequently found myself yelling in my head to Nancy: "Why can't you see you're an amazing parent? It's right in front of you!" I often have to remind myself to slow down, that emotional trauma is like a wound and the process of healing requires an atmosphere of safety and time to repair.

All of this gave me a perspective that allowed me to trust that she's always had the instincts to do what's best for her family. These sessions, and the insights that came out of them, fostered the development of healthier boundaries for herself and improved communications within the family context.

Nancy struggled mightily with parental boundaries because she was convinced that she was an "enabler," feeling enormous responsibility for Rick's struggles. When my clients talk about being enablers I want to scream. My job helping families create healthier boundaries is made much harder by the myth of the enabler, which shifts natural parental love and nurturing into a badge of shame and failure. The enabling myth is a remnant from the one-size-fits-all "tough love" approach, which prevents struggling family members from maintaining a connection to the only people who truly care about them.

The trauma of the ongoing abuse that Nancy experienced as a child contributed to a psychological default position in which the world is an unsafe, frightening place- a world view experienced by many victims of this type of abuse. She struggled for many years with severe anxiety, hypervigilance, depression with suicidal ideation, dissociation and intrusive memories that were highly disruptive to her everyday functioning.

Much of our work focused on developing strategies for managing her disruptive PTSD symptoms, a process that included helping her understand how PTSD symptoms can be functional. For example, Nancy's hypervigilance, and her ability to compartmentalize feelings via dissociation, were actually advantageous in the sense that they helped her take good care of Rick during his childhood illness. They also made her an expert at crisis management, a skill necessary to deal with her son's lifelong mental health and substance use issues. Obviously, the downside of these adaptive characteristics is that over time they can take a severe physical and emotional toll. It can feel like a switch that's turned on to high volume, and at times, can't be easily turned off. Sometimes these symptoms of Nancy's were triggered by events associated with the original abuse, but at other times they would appear seemingly without connection to any trigger.

For example, there were times during therapy sessions when Nancy's face would glaze over and although she'd be participating in the conversation, it was clear that she was not emotionally present and able to benefit from our interaction. This is a sign of dissociating and it gave me an opportunity to witness this process with her, help her make a connection with what triggered the episode and give her in-vivo tools to help ground herself and feel safer while processing the unsettling material.

Psychotherapy enabled her to understand the aspects of her PTSD symptoms that served as positive coping skills, empower her to creatively embrace their benefits, while also learning the mindfulness skills she needed to regain the balance needed to manage the emotional disruption they can cause.

Enhancing empowerment and hope

Families struggling with addiction benefit from measures of hope to help them move forward. The stage of change model demonstrates that change is not a single threshold that we step over, but a dynamic, ongoing process. As described here, we don't change all at once, but rather, in stages (Precontemplation, Contemplation, Preparation, Action and Maintenance). Interestingly, and unfortunately, with substance use we often ignore this natural process and expect people to just stop using and change their lifestyle all at once.

It's important to understand that the stages aren't mutually exclusive and people generally don't move through them in a linear way. With most significant changes, adjustment is a stepwise process in which the individual takes small positive steps forward but may often move backwards until the confidence to move forward returns again.

For Nancy, the stages of change model has been particularly useful in helping her gain understanding of her own journey through multiple addictions as well as in pursuit of an understanding of her son's problems. For most of Nancy's adult life, she was firmly in the precontemplation stage of recovery with respect to alcohol, followed by a few years of contemplation once she began treatment; and preparation, action and maintenance followed relatively quickly. When Nancy made enough progress to see that drinking alcohol made her dissociation worse, she more clearly saw the downside of drinking and it helped move her from the contemplation stage to the preparation stage. In contrast, her path to recovery for sex addiction was marked by a short period of precontemplation, a very long time in contemplation, a longer time in preparation and action before arriving in maintenance. Mountains of guilt and shame from her sex addiction bogged her down in the contemplation stage but her participation in the support group helped to chip away at these emotions and eventually made her more willing to tackle the difficult work in preparation and action stages. (Of course, Nancy's struggles for recovery were not as linear as this I'm simplifying here for the sake of example.)

A turning point for Nancy occurred when she saw the processes of change in her own addiction recovery being mirrored by the process that she, and her family, were going through in understanding and accepting Rick's addiction. Nancy was agonizing in a session that she didn't know how much more she could take of her rollercoaster life with Rick. He had just returned to jail for the third time; this time a two-year-sentence awaited him for a probation violation after doing really well for about nine months at a sober living home. "I'm sick. I'm done. Maybe tough love is the best way to go, because I can't take this anymore," she exclaimed.

Together, we took a step back and looked at Rick's recovery path, which, despite this setback, more recently included increasing levels of motivation and greater periods of sustained sobriety. I asked her to compare it to her own recovery paths, which by now she had understood. I was proud of her and felt relieved when she said, "Wow, yes, I can see his progress despite how horrible it feels now!"

The understanding was liberating for her because the exercise validated her progress in all three areas of her struggle. When we reviewed Rick's stages of change, it was an epiphany for her, giving her insight into their shared struggle and allowing her to finally let go of much of the hurt, anger, helplessness and hopelessness she felt with Rick. She felt empowered as a parent, letting go much of the guilt, certain now that she had, as she put it, "broken the chain of abuse in my family."

My work with Nancy, and her family, has allowed Nancy to tap into her strengths and resources and use them to effectively support Rick, who after many attempts and failures, is firmly in the action stage and engaged in treatment as never before. She also gained insight into her own recovery and healing process, and is much better able to take care of herself as she moves forward in her life. Most importantly, she has what I think may be the most important element that families need to cope with a substance using family member - she has hope. Hope gives us some respite from the feelings of hopelessness and despair commonly felt in substance using families. Hope is healing and gives Nancy the strength to move forward.

Barry Lessin is a Licensed Psychologist with a private practice in Philadelphia and almost 40 years of work as a clinician, administrator, educator, researcher and drug policy reformer.

[Professional Voices is designed to provide a forum for clinicians to exchange ideas about good treatment and highlight concepts, techniques and interventions that have proved important in their work with clients. What do you think are the essential elements of effective treatment in addiction treatment?]