Don’t Waste Good Drugs on a Bad Mood and Other Ideas For These Times
I work with people who take drugs,(fun fact: alcohol is also a drug). Sometimes a person knows that they want to stop, but most of the time they want to rewind their drug use, in someway go back to a time and place when the drug was fun, or managed emotions better, or was not obliterating the rest their life. I started working in the recovery industry in the late 1980's, so I can sing the 12- steps backwards and forwards like my ABC’s. Don’t get me wrong, I love the 12- steps. This intervention is time-worn and can reorganize many a chaotic user into a more user-friendly version of themselves. The problem with the 12--steps is that many people dont want to quit using, or they don’t like the Higher Power unmanageable language, or the idea of forever-quitting is too anxiety provoking. The Big Book of Alcoholics Anonymous is written in a very old fashioned language so if you are not a reader, it is easy to miss the wisdom in it. The Victorian language can be a meditation in a certain activated Christian mode, but is only useful if you recognize the viability of its ideas. Some people have been forced into it by a family member or a court and cannot receive The AA message, even if it might be a good option, and anyway they don’t want to quit. I work with people who usually don’t want, or have failed at traditional recovery.
Many people see that they have a problem, but not the one size solution. Abstinence by the very nature of the word creates a natural abhorrence. It is a perfect way not to get pregnant, but an utterly horrible solution for people who like sex. Semantics of the abstinence-based recovery world creates a gap between the helper or family member and the substance user. Helpers sing a song of abstinence and the user’s solo is to make the trouble go away. In the helper’s mind, trouble equals drugs, but in the person’s mind, trouble is a puzzle to be solved and often emanating from another source. The meaning of words must be sorted out in the most basic way before change is possible.
In most usual drug treatment, there is very little latitude to think out loud about these things. Therapy/helper business prescribes abstinence when you walk in the door with a problem. As soon as someone puts a substance use issue out there, the oxygen in the room is sucked up by everyone’s advice, and all or nothing abstinence oriented interventions.
In my professional life, I am living through my second or third heroin epidemic. That is how old I am. I have also worked my way through the cocaine and crack, meth epidemics as well as sex addiction, relationship addiction, video addiction and I guess now social media addiction. So in my travels I have picked up some ways of organizing my thoughts around substance use and difficulties that accompany them. I became a Harm Reductionist because I hate kicking people out for the behavior that a someone needs help with. Below are my Harm Reduction needlepoint pillow ideas. They are guideposts for work with substance use disorders and also for users who are inevitably the best sorter of what they should do next.
#1.Behavior is just behavior. It’s what we do to manage the intensity of our own human messiness. Some behaviors are hidden, and some are visible. All behaviors have the potential to stop working for the purpose or to accumulate negative effects. As a harm reductionist, I believe that people use drugs for reasons and sometimes the behavior is the thing that gets the attention to the underlying reason. Mostly I am talking about the behaviors that we judge as bad or dangerous because we don’t like them for ourselves and then we project this judgement on other people. If you are having trouble thinking about a specific behavior, then substitute another behavior in it’s place to decrease the judgement and see pathways to change more clearly. This thought exercise always works to decrease judgements.
I am not saying that people don’t experience significant brain changes with high risk substance use disorders (SUD), or other behaviors, I am just saying that I have been part of so many unexpected miracles of behavioral change when the person was offered an empathic and guiding partner relationship, regardless of whether they gave up their substances, or followed the path prescribed by most SUD professionals. So while I understand substance use problems like the heroin epidemic is of grave concern, I also know that we need more services that orient around harm reduction first and the rapport and possibility that that relationship bring.
Part of the challenge with high risk substance use, like heroin is that both the user and the helper, are backed into an isolated corner dependent on a particular outcome rather than exploring many possible outcomes in the context of a therapeutic attachment. Many states have intervened with supplies and prescribing culture, and put physicians at odds with the people who need their collaborative problem solving skills the most. Many healthcare professionals carry a high level of anger and frustration at users and divorce themselves from meaningful collaborations that could save lives and create the elements needed for lasting change. If you are aware of judgement and frustration about client behaviors, you need help out of this struggle to continue ethical practice.
Opiate dependence creates quite a tension between the user, their family and almost all professionals who cannot understand the internal experience of dependence and withdrawal, but think that they do. If you hold only one definition of success everybody becomes frustrated.
So my job has often been to ride shotgun with a drug user and explore first the ways to stay alive and then later perhaps, the way to get more of what you want and less of what you dont want.
#2. What do you want the drug to do — - And is it doing it?
People use drugs for reasons and while they have some idea of the desired effect, they often have no venue to explore the nuance and efficacy of this expectation. Often the user asks the drug to manage a mood up for a Saturday night or offer amnesia about the pain of a breakup or just help sleep. Any drug will take care of some of our emotional and comfort business for a short time, but it is unfair and usually ineffective to ask the alcohol or the joint to cover all emotional anxiety and lay a foundation of endless comfort. Sooner or later the wine stops working or it works unpredictably. The problem with pain medicine is that it makes more pain as it wears off and that is the paradox with many substances. One might use meth because it co-creates with the brain to create a hellacious sexual response, but eventually, that feature becomes significantly lonely and depersonalizing to what the rest of the psyche needs.
Many people that I have talked to tell me an old story of the drug’s effectiveness. It’s a nostalgia box; a lost Xanadu of pleasure and fun, rather than the present reality of punishing consequences and uncertainty. That euphoric recall for a happier use narrative, serves a soothing function to the irritated agitated user. Traditional treatment blocks this discussion rather than gently refocusing it on the present with the addition of the connected helper to hold the stress with the client.
In College or as newly-minted adults in the world, substances often assist with social anxiety and establishing sexual behaviors and help us to dance in public because of its euphoria and disinhibition effects. Also there is often a group-think. We bond with others obtaining similar effects so the experience is often social first. Somewhere along the way, the extra effects of the drug may cause a rational decision to skip the social part and just light up a joint as soon as you get home to medicate the discomfort accumulated in a stressful life with no other coping skills except the pot. The use shifts from instigating fun or pleasure to medicating a spectrum of discomfort from boredom to trauma.
# 3. What gives you pleasure? How diverse is your pleasure diet? What is your pleasure philosophy and what are the rules you have about pleasure? Many people who experience complicated substance use difficulties, also have complex conditions regarding pleasure. Pleasure is often an under-served experience in life Users who associate drugs and fun, fear the lack of pleasure that they may experience if they change or limit or give up problematic substance use. Even if the pleasure is long-gone from the drug use, the anticipation that it is might somehow arrive again makes life worth living. How able are you able to activate and experience pleasure without substances? Can you dance sober anytime any place like me? Since many substances eventually create a numbing effect or a long-term decrease in brain pleasure chemistry, pleasure is a very important aspect of life to pay attention to when negotiating substance behavior change. Pure unmediated pleasure is good competition to substance induced pleasure but this is often a lost or never learned art.
#4. Any Change from the status quo is valuable. Human beings are always in a dance with change, which is inevitable, and are also holding tight to the status quo which is familiar and comfortable. We are hard wired for both of these endeavors and often become rigid in behaviors that create the most uncertainty and even accumulating negative consequences to avoid that first small step. Watch a child with a security blanket that wont let go for the mother to wash off years of dirt.
When I work with chronic users, I am often struck with the feeling of Groundhog Day, (as in the Bill Murray Film). The conversations and situations are so repetitive that we as helpers are lulled into an extremely dysfunctional repetition. One small change, usually around safety or comfort breaks the spell. I remember the breakthrough question I had with a long-term alcoholic man. (I always refer to these clients as my drunk uncles because it feels like that with them — different day; same story) It is frustrating and energetically dull and sluggish. Like Groundhog Day with no surprise. So the question has to be: What would we be talking about if we weren’t always talking about your drinking? The first time I asked a client this question, his eyes looked startled and after a moment he began talking in a way that was new and different for both of us. He told me about his dog and the sadness he had without her since he couldn’t keep her on the road any more. It was a breathtaking conversation and led to him strategizing about how he could get some time with a new dog without taking a dog on full-time. This change organized many more gentle changes that ultimately gave him the idea of lowering amounts and frequency of drinking. It also introduced pleasure and a competing need to mange drinking to be available for dog-walking at the local shelter. This phenomenon of small changes breeding larger ones, which is a cornerstone of Motivational Interviewing, Harm Reduction Psychotherapy and other and Behavior Change Theory, and that I have written about before in the New Incrementalism is like a super power when working with chaotic and chronic substance users. How our profession will protect and offer this kind of helping relationship in the current political weather will be a challenge.
#5. Don’t waste good drugs on a bad mood. This elegant maxim worthy of any needlepoint pillow sold on ETSY, came from a client I was working with whose goal was to create a planned use for Methamphetamine. Now let me say that when I work with clients whose goals sound like this, I certainly have a voice in my head that says: That is impossible! You can’t do that! However, this was his idea and he was most motivated toward this. Motivation is like a rare bird sighting precious and at times fleeting. It’s important not to disturb it’s flow while you explore the meaning of it. One of the things that many people don’t understand about Harm Reduction modalities, is that in addition to directive interventions toward safety and lowering risk, harm reduction also offers quite a bit of direction and structure when people want to explore a return to some kind of moderate use pattern.
In this case the client wanted to work. on a moderate use pattern for meth and I let him know that if he wanted to do this in a Harm Reduction mode, he would have to first abstain from Meth for a significant amount of time and work on coping skills and anything else that abstinence brought to the surface. No problem he said. This was a profound moment, since he had just agreed to an abstinence plan so that he could test out his hypothesis that he could return to planned use. He would not have agreed to an abstinence of the forever variety if I had proposed it.
He maintained a year-long abstinence, (a mutually agreed upon time frame based on his willingness and also hope for success to return to non- problematic use). He experienced many benefits of his time out so, that I was hoping that he would continue the abstinence, but at a year he let me know that he wanted to begin to make his planned-use recipe. I knew that like all plans it must come from him and be detailed and organized, time relevant and accommodate his ability. He told me that the first thing he knew was that he shouldn’t waste good drugs on a bad mood and he was glad that I had asked him to abstain and work on many of the things that he was hurting over. He made a very safe very conscious plan and even postponed it when something negative happened saying: I didn’t want to waste good drugs on a bad mood.
His return to meth was mixed in terms of pleasure but he was able to stick to his plan including flushing his remaining drugs at the end of the weekend and taking a Xanax to help him transition days. When we talked about it, it sounded like he had visited an old neighborhood and realized that he couldn’t live there any more. He ultimately decided to stay abstinent from meth after this experience, but was able to drink socially in a satisfying way. While I am sure I helped him with my neutral curious stance, he helped me even more with this single most important harm reduction statement I have ever heard or shared. It never fails to get the conversation going in a new direction: Don’t waste good drugs on a bad mood. ©2017 annie fahy