I’ve seen quite a few articles discussing the integration of 12-step and recovery concepts into models such as cognitive-behavioral, psychodynamic, or other clinical orientations. Rarely, if ever, have I seen a discussion that goes the other way, addressing the problem of what happens when a recovery-based approach fails to motivate or engage a client struggling with addiction. In this article I attempt to describe the leap of faith I took in working with a young adult who did not respond positively to a recovery, motivational or cognitive-behavioral based approach, leading me to alter my therapeutic stance and surrender more deeply to the process.
First, a little context: At this time, I was newly licensed in Marriage and Family Therapy working both in a treatment center for drugs and alcohol and in private practice. I also was (and am) a proud member of the recovery community and a supporter of 12-step-based programs and other programs that have demonstrated some efficacy against addiction. My faith in the psychotherapeutic process, especially for fighting addiction, was not yet as strong. The treatment center, a modestly upscale residential program in Los Angeles, was founded on the principles of Alcoholics Anonymous.
The program included three groups per day—mostly psychoeducational, 12-step-based or peer-supportive—as well as one daily 12-step meeting in the community, usually AA or NA (Narcotics Anonymous). The rest of the program was essentially a social-behavioral model, based on the AA concepts that recovery is a “program of action” and that “if you move your feet, the heart and mind will follow.” Added to the mix was the notion that “no one recovers alone.” Residents were asked to follow a structured daily regimen, including completing chores, making their bed, attending all groups on time, socially engaging with peers, and so forth. The population tended to skew—by chance, rather than design—towards young adults 18-25 years old who struggled with “failure to launch” issues.
My 22-year-old client Stan fit this profile well. He was referred to my private practice by a psychiatrist treating him for depression. He was a reserved but personable young man, given to anxiety, crippling self-doubt, and chronic marijuana use. He was ambivalent about pot, stating that it soothed and relaxed him but kept him from his goals. These goals were vague in definition, other than a longed-for sense of “moving forward,” staying “disciplined,” and “getting organized.” This vagueness indicated to me that these goals were internal: He craved confidence, which eluded him, creating a profound anxiety that gnawed at him constantly. In fact, Stan’s “stuckness” and deteriorating daily living skills led to a kind of slow-motion panic, which he suppressed with exaggerated machismo. Underneath that bravado, however, the anxiety triggered cravings for pot, thus perpetuating the cycle.
I also suspected that marijuana was a way of “protecting” himself from the intensity of an intrusive mother, Cheryl, still reeling from her divorce several years prior. Stan’s dad had left the family when Stan was 15, at which point his mother moved herself and her children (Stan and his younger sister) from Seattle to Chicago, where her family lived. This uprooting was traumatic to Stan, since he’d developed a close group of friends in Seattle, as well as a burgeoning baseball career. After moving to Chicago, his playing sputtered: home runs became strike-outs, leading to disillusionment and paralyzing self-doubt. Cheryl’s response was to barrage and smother him with motherly concern. Even now she checked on him constantly, pushing him via phone and email to “get it together,” pay his bills and late parking tickets, complete his homework, and so on.
Therapy with Stan was slow going at first. He was reluctant to trust any authority figures, like most young adults, which made sense the more Stan talked about his yearning for a strong male role model. “He never imparted any wisdom,” said Stan about his own dad, whose moody self-absorption and physical absence was felt keenly as an abandonment.
My initial approach was to first develop a therapeutic alliance by providing emotional safety, openness and empathic reflection, a “holding environment” within which he could express some of his difficult feelings. It was important, I saw, to acknowledge not only the painful struggle with these feelings but also that this struggle violated the strong male ideal he longed for. (One of my longer-term goals was to help him shift this ideal to something less black and white. I soon saw that this, like our crucial alliance building, was going to take some time.) Second, I explored and assessed Stan’s marijuana use. What he revealed to me was alarming: smoking was endangering his grades, his job, and even his residence. In short, the money his mother gave him for rent, education, and other expenses was being swallowed up by chronic use of “the chronic.”
Concerning too was Stan’s attitude towards all this, which as noted was ambivalent; he recognized pot interfered with his life, occasionally called it “addictive,” but mostly remained in denial, stating that none of his problems were a big deal, since he was “getting ready” to cut down or give up pot completely, while his girlfriend and mother were “overreacting” to his smoking. He acknowledged, of course, that it probably was not the best idea to borrow large sums from his friend/dealer in order to purchase marijuana at wholesale prices—especially since he had lost his job and had no real means of paying the guy back. Oh sure, this “friend” was known to get violent, but not with people who were “chill”, like my client.
I found myself secretly sympathizing with his mother…
Of course I had to be careful. Stan and I were still at early goings in what I sensed was a “testing” phase wherein he was watching me carefully to see how I would react to these jarring news bulletins: tales of his dissolution. To react too intensely would be to alienate or even lose him at a time when we were forming a very tentative but real connection. To remain ever neutral, however, might come off as indifference or lack of concern.
The fact that he attended consistently, and mostly on time, told me he took our work seriously. He told me he had never discussed any of his difficult feelings with anyone; I suspected he was torn dramatically between rage at his mother—who was constantly “haranguing” him—and sympathy for her after being “dumped by her husband” and was now struggling to make ends meet and dealing with a “son who was messing up.”
Thus I tried—gently, with gradually increasing oomph—a variety of psychoeducational and motivation-building techniques, in addition to the psychodynamic explorations above, in the hope of helping him comprehend the danger of chronic marijuana use to still-developing brains, the harm that can result from excessive use, especially given his confirmed diagnosis of depression. As a former pot-head myself, I knew how soothing pot was before it became deeply problematic. I also tried reframing abuse or dependence as an illness, rather than a weakness—much like his depression, which he had accepted (and had taken medication for, without complaint). None of it worked. He agreed with all of the above—complied, I now think—and agreed to our “plan” to stop smoking, at least until his grades turned around, and to begin attending MA (Marijuana Anonymous) meetings, if only once or twice, to learn how others managed without pot.
Great, I said, and provided him with an MA directory. He never went.
Even when he got put on academic probation. Or lost his apartment. Or had his finances cut off by mom. Or began sleeping in his car. I started each session by inquiring, with escalating concern, if he’d attended any MA meetings. He always had the same response: “No, but I will.”
Then one day, he stopped coming. His phone service was cancelled. I had no way to reach him. I did receive a voicemail from him, sounding distracted and disoriented. I decided to refer his mother to an interventionist, who arranged for family members to fly to L.A. and confront Stan about his use. They did, and he agreed to rehab—with great reluctance. (This rehab was similar to the one where I worked.)
This story will be continued in Part 2.
Related articles:
Bottoming Out Twice
Tomorrowland: Stuck in an Imaginary Future – A User’s Dilemma
Psychotherapy Helps in Coping With Anxiety or Depression
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