Effectively Treating Substance Abuse
Gibbs A. Williams, Ph.D.


From an article in the New York Times 11/12/92 entitled: Study Cites Role of Biological and Genetic Factors in Violence: A new approach is needed to open ''a pathway out of the current stalemate between the right and the left about crime,'' Professor Moore said. [Mark H. professor of criminal justice policy at Harvard University]. ''The right is saying, All we need are more prisons and police," he said. ''The left says, That is a stupid waste of money. What we really need is to abolish poverty and racial discrimination.'' The report, he said, ''seeks a new middle ground.''

My proposed workshop on Frustration Intolerance and The Substance Abuser aims to both identify ''a new middle ground and to provide a cost effective program in working with addicts.''

The Problem:
Parallel to the neglect of the physical infrastructure re rotting bridges, roads, tunnels is the neglect of a goodly amount of the psychological infrastructure expressed in a number of escalating behaviors including:

· substance abuse

· rising crime rate, increasing rapes, murders

· continuing warehousing of great numbers of addicts

  seen in an expansion of new jails

· child abuse

· battered love syndrome

· random violence

· a crisis in education

All of these indicators of disruptive anti-social behavior may be regarded as symptoms of an underlying psychological disorder: namely impulsivity expressed in the form of an incohesive self.

Definition:
People who suffer from impulsivity are essentially reactive (act out) rather than reflect (act from within.) All impulsive personalities may be said to suffer from a moderate to severe allergy to frustration.

Causes:
From the perspective of the individual, impulsivity is a derivative of an incohesive {under structured} self. Self is operationally defined as something solid at the core that is able to persist in the midst of internal and external confusion. An incohesive self is prone to psychological collapse in the face of intolerable pressure (intolerable frustration).

The preconditions for the formation of a cohesive self is the capacity to bear increasing dosages of frustration and other so called negative affects and to be able to make and enforce appropriate self and ego boundaries. Examples of these boundaries are:

(l) Content Boundaries: Making distinctions between and among feelings, thoughts, judgements/actions;

(2) Spatial Boundaries

      (a) separating inside (psychodynamic, intrapsychic reality)
            from external (consensually validated) reality and

      (b) distinguishing bounded space (normal adult perception)
            from unbounded (a baby's perception of space) and

(3) Temporal Boundaries:

      (a) distinguishing linear time (past/present/future)
            from durational time (now or vacation time) and

      (b) distinguishing the here and now (objective present)
            from the there and then (transference).

Process:
Refer to the manual on Fundamental Concepts and Techniques In Working With Substance Abusers; the paper called Psychodynamics of Spirituality: The Higher Power and the Personal Unconscious and the Concrete Intervention Outline (Exercises).

Aims:
provide a clear framework ( psychological map) so the patient and his counselor can clearly see the war they are waging.

Stimulate the abuser in becoming increasingly more curious and interested in his psychology by introducing him to the facts of his interior reality and complexity (like taking off the cover of a complicated watch to see what makes it tick).

Fill in the 0 in the formula S O R where S = stimulus; 0 = self; and R = response.

Describe and illustrate representative problems that occur when one is missing a cohesive self. The lack of a self-structure is equivalent to a person having a frustration allergy that is the inability to gracefully accept and tolerate inevitable frustration. This means that when the person is frustrated- indicating they are disappointed because of a missed expectation - they will try to ward off the frustration rather than to use it as a jumping off point to generate a creative solution to solve an undeniable personal problem.

Normal Frustration:
The capacity to tolerate frustration is critical in adequately resolving personal problems. This is so because creative problem solving is dependent on using past experience as a guide to present informed decision making. When we have a problem in the present that seems initially overwhelming it is normal to become frustrated. At this point, rationality takes over and we try to compare present experience with similar situations from the past. In order to access and to utilize the past as a guide to the present it is first necessary to delay action at the point in the present when frustrated. The delay of response allows time to recall past events that are similar to the present situation as well as thinking about what was learned from them. The operational definition of delay when applied to an attitude about frustration is the act of tolerating present frustration - not liking it but accepting it as real.

When normal frustration is denied, or reacted to with anger turned in on the self it results in the reality of the self as well as external reality to be perceived as fragmented, discontinuous, estranged, and randomly held together. When frustration is accepted as inevitable, the reality of the self and external reality is perceived as united, having continuity, contiguity and causality.

An Application of these ideas:
Mike C (herein referred to as M) Cocaine Dynamics Session Notes:

Note: Up to this point M has experienced frustration as a weakness hence his feeling out of control. He has tended to become angry and depressed at himself when frustrated habitually turning to drugs for solace. But his drug tasking which used to work for him is instead now perceived as an even greater weakness than the frustration that has motivated him to use it.

This session began with a dream:

I move back into a tiny apartment with bare walls. I don't want to go back to this. {He is referring to his cocaine life style which he is presently considering to be a waste of his time and money}Note: At this point in his treatment his increasing displeasure of his cocaine life style is gaining in ascendancy with his habitual temptation to flirt with it).

Trigger for his conflict. {Explaining what has happened in the present which has motivated him to even consider returning to coke}.

M states that he received an unexpected $7000.00 tax bill experiencing it as a big blow. He was aware that in the past he would have predictably reacted by instantly snorting coke. Cocaine would have had the effect of blanking out unwanted intolerable "negative" feelings of inadequacy and failure expressed as " no matter what I do it is never enough." Not enough = a negative self-evaluation of insufficiency and inadequacy. It was as if he was feeling that the world/ /external reality is too big and that he is by comparison too small and insubstantial to effectively handle his problems.

(Note: His self concept was previously based on an ego ideal of the myth of perfect God-like control -omniscient and omnipotent - an ideal which was mostly unconscious. This impossible expectation was sorely tested by the brute reality of the tax bill, he initially felt to be overwhelming. In self-esteem deregulation a missed expectation experienced as a disappointment (frustration) leads to anger turned in on the self. This confluence of feelings combines with additional feelings of empty insubstantiality, weakness and negative moral indictments of shame, guilt, helplessness, hopelessness, and fears of actual and or imagined psychological and sometimes physical collapse. The resulting negative self concept and lack of empowerment is further experienced as despicable adding even more fuel to the already destructive fire of ever diminishing self -esteem.

Problems of Affect Intolerance and Fluid Boundaries:

His central psychological problem has been an inability to effectively regulate his self -esteem. Thus when beset by unexpected pressures (experienced as blows) he has tended to personalize them punitively judging his initial reaction of inadequacy as abnormal hence debasing. In short, he is overwhelmed by feeling overwhelmed. In other terms he is frustrated feeling normal frustration judging it to be a measure of how ineffectual and imperfect he is rather than as something that is normal having to be creatively coped with. Initially this unacceptable self- concept and self -feeling was associated with fears of unconsciously wished for but consciously dreaded fantasies and feelings of frustrated needs for love, abandonment, collapse and rescue.

Note that initially M was unaware (unconscious) of his first assumption that frustration should never occur and that if it did he should be able to instantly and permanently rid himself of its unpleasantness. In its place was an illusory fantasy of absolute control taking the form of an ego idea of complete self-sufficiency. Thus when he was unable to meet this impossible expectation of discounting the inevitability of realistic limits and limitations he was initially ashamed of his inability to be in control.

Intervention:

Systematic attention to the implementing the tasks outlined under Aims. This therapeutic focus on promoting affect tolerance and recognizing the need to make and then to implement making appropriate self and ego boundaries led to an increasing capacity to regulate his self-esteem. This in turn led M to feel increasingly more empowered expressed as his experiencing himself as increasingly more secure, confident and in middle level control. {Middle level control refers to the idea of appropriate realistic control as contrasted with hyper illusory control associated with grandiose fantasies of omniscience and omnipotence on the one side versus hypo control associated with fantasies of total inadequacy and ineffectualness on the other.}

M's Confirmation of the Power of Connecting with and Utilizing Core Concepts

In the next session M responded to the above with another dream:

My father is 20 - feet tall. I'm a child but it is me now. My father is leaving. I have a concave feeling like I want to cry. I do cry and feel as though I'm coming apart. As my eyes are closed, I know that when I open them he won't be there. I open my eyes and see that my father has gone. I feel lost

M associated that this is what he actually felt in the past many times - but instead of crying he would tough it out denying that he felt anything - thereby avoiding a connection with his real and imagined fears of being afraid, lost and confused. To be noted: is his subsequent cover up of his wish for love converted into an illusory ideal of pseudo self sufficiency that was defensive protecting him from directly experiencing overwhelming pain associated with frustrated needs for parental love. Thus no guidance was provided teaching him how to tolerate the inevitability of negative experiences summarized as frustration. Nor was he taught how to make necessary ego and self- boundaries with respect to space, time and contents of consciousness.

Thus, when feeling initially overwhelmed by an unexpected blow/pressure such as the surprise tax bill, he initially identified himself as the collective negative feelings instead of distancing himself from them with the knowledge that his self is more than the temporary negative feelings of the moment. This is the typical experience of the addict who at such times when he feels over whelmed by frustration often states that he has lost himself - that he feels out of it. The intervention that the self is more than the feelings of the moment is the equivalent of making a self-boundary, encouraging the person to absorb rather than to fight his painful but inevitable disappointments. Such interventions help the abuser utilize his rationality to aid himself in constructing a solid cohesive self.

Gibbs A. Williams, Ph.D. © 1999-2000