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Stephanie Brown on Treating Addictions in Psychotherapy

by Randall C. Wyatt and Victor Yalom

Stephanie Brown discusses treating alcoholism, chemical dependency and other addictions in psychotherapy.

Filed Under: Addiction, Alcoholism

Earn CE Credit

In This Interview…

What happens when people stop drinking?
The Addiction Accounting System
Binge Drinking
Addiction to Drugs, Prescription Meds, Food, Gambling
Sentenced Treatments and Addiction Outcomes
What do therapists who don't specialize in addictions need to know?
Brown on Harm Reduction Recovery Models
The Developmental Model of Addiction and Recovery
Understanding Therapist Impatience and Frustration in Addiction Work
Psychotherapy, AA and Spirituality
Integrating Addiction and Psychotherapeutic Work
The Most Rewarding Part of Addictions Work

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. 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."

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."

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.

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.

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.

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.

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.

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. 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.

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.

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Disclosures

Stephanie Brown, PhD, is a clinician, author, teacher, researcher, and consultant in the field of addictions. She is a licensed psychologist with over 35 years of clinical experience and an internationally recognized expert on the trauma and the treatment of alcoholics and their families. Dr. Brown is currently the Director of The Addictions Institute in Menlo Park, California, an outpatient clinic, and a Research Associate at the Mental Research Institute (MRI) in Palo Alto, CA, where she co-directs The Family Recovery Research Project. She is currently applying this research to the development of a new extended family treatment program at Mayflower in Marin County. She is also Consulting Director of the Institute on Addictions at the California School of Professional Psychology at Alliant International University in San Francisco. Dr. Brown founded the Alcohol Clinic at Stanford University Medical Center in 1977 and served as its director for eight years, developing the dynamic model of alcoholism recovery and its application to the long-term treatment of all members of an alcoholic family. Dr. Brown served on the California State Alcoholism Advisory Board and was a founding member of the National Association for Children of Alcoholics (NACOA.) Visit Stephanie Brown's Addictions Institute website.

Awards: Dr. Brown received the Bronze Key Award (1983) and the Humanitarian Award (1984) from the National Council on Alcoholism and the Community Service Award from the California Society for the Treatment of Alcoholism and other Drug Dependencies in 1986. In 1991 she received an Academic Specialist Award from the U.S.I.A. to teach in Poland. More recently, she received the Norman Zinberg Memorial Award from Harvard University (2000), the Clark Vincent Award from the California Association of Marriage and Family Therapists (2001), and the Janet Geringer Woititz award from Health Communications, Inc. (2005).

Books and Videos: Dr. Brown is the author of Treating the Alcoholic, and Treating Adult Children of Alcoholics, and Editor of Treating Alcoholism, and A Place Called Self: Women, Sobriety and Radical Transformation. Her latest book is Speed: Facing our Addiction to Faster and Faster--and Overcoming our Fear of Slowing Down. She is coauthor of The Alcoholic Family in Recovery: A Developmental Model, and The Family Recovery Guide and co-editor of The Handbook of Addiction Treatment for Women. She has also completed two training videos, Treating Alcoholism in Psychotherapy and Stages of Family Recovery. She lectures widely and maintains a private practice.

Stephanie Brown was compensated for his/her/their contribution. None of his/her/their books or additional offerings are required for any of the Psychotherapy.net content. Should such materials be references, it is as an additional resource.

Psychotherapy.net defines ineligible companies as those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. There is no minimum financial threshold; individuals must disclose all financial relationships, regardless of the amount, with ineligible companies. We ask that all contributors disclose any and all financial relationships they have with any ineligible companies whether the individual views them as relevant to the education or not.

Additionally, there is no commercial support for this activity. None of the planners or any employee at Psychotherapy.net who has worked on this educational activity has relevant financial relationship(s) to disclose with ineligible companies.

Randall C. Wyatt, PhD is a practicing psychologist in Oakland and Dublin, California. He specializes in working with post-traumatic stress, cross-cultural therapeutic relationships and couples therapy and has extensive teaching experience.

Randall C. Wyatt was compensated for his/her/their contribution. None of his/her/their books or additional offerings are required for any of the Psychotherapy.net content. Should such materials be references, it is as an additional resource.

Psychotherapy.net defines ineligible companies as those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. There is no minimum financial threshold; individuals must disclose all financial relationships, regardless of the amount, with ineligible companies. We ask that all contributors disclose any and all financial relationships they have with any ineligible companies whether the individual views them as relevant to the education or not.

Additionally, there is no commercial support for this activity. None of the planners or any employee at Psychotherapy.net who has worked on this educational activity has relevant financial relationship(s) to disclose with ineligible companies.

Victor Yalom, PhD is the founder and resident cartoonist of Psychotherapy.net. He maintained a busy private practice in San Francisco for over 25 years, but now sees only a few clients, devoting the bulk of his time to creating new training videos for Psychotherapy.net. He has produced over 100 videos, conducted workshops in existential-humanistic and group therapy in the US, Mexico, and China, and currently leads consultation groups for therapists. More info on Victor and his artwork and sculpture at sfpsychologist.com.

Victor Yalom was compensated for his/her/their contribution. None of his/her/their books or additional offerings are required for any of the Psychotherapy.net content. Should such materials be references, it is as an additional resource.

Psychotherapy.net defines ineligible companies as those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. There is no minimum financial threshold; individuals must disclose all financial relationships, regardless of the amount, with ineligible companies. We ask that all contributors disclose any and all financial relationships they have with any ineligible companies whether the individual views them as relevant to the education or not.

Additionally, there is no commercial support for this activity. None of the planners or any employee at Psychotherapy.net who has worked on this educational activity has relevant financial relationship(s) to disclose with ineligible companies.

CE credits: 2

Learning Objectives:

Describe Brown's attachment-based view of addiction
Explain how to use psychotherapy with addictions.
Integrate discussions of 12-step programs into psychotherapy

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