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Outpatients are Not Treating Addiction

When a client comes to treatment for addiction, in an outpatient or residential setting, we obviously explore their symptoms. Tolerance, cravings, withdrawal, unsuccessful attempts at stopping, reoccurring dangerous situations, and increased amount of time thinking or obtaining the drug are not typically cited as reasons to come to treatment by the client. These are not symptoms that individuals directly identify with because they are not the most pressing concerns to the client. On some level, clients in treatment recognize these diagnostic symptoms and their drug use as an issue but more often they recognize the underlying emotional issues. If we are to meet the client where they are at, the underlying emotional stress is where it is.

The rollercoaster of diagnostic addictive symptoms seems elusive to the client because they are medical and existential in nature. First responders, ER’s, detox units, and in-patient deal with active addiction. So do families, friends, community members, employees, and employers. “Addiction” is happening at breakfast, lunch, and dinner. “Addiction” is happening on Friday night happy hour, Wednesday night bingo, 2 a.m. coke binge, and at family functions. “Addiction” is happening on a boat, on a plane, on a stage, and in a cage. It is happening in the normal hustle and bustle of day-to-day life. In the outpatient setting, the problem is separating the outside world from the therapy setting. This begs the question: what are we really treating in our outpatient and residential settings?

What are the psychological symptoms that clients experience days, weeks, or months, or even years after their last use? Clients may say “I can’t stop using,” I don’t want to be here.” “I don’t want to go back,” “I can’t cope,” and “I can’t control it.” In other words, they report that they are experiencing intrusive thoughts, avoidance of remembrances, negative alterations in cognition and mood, and alterations in arousal and reactivity. These are post-traumatic stress symptoms.

I prefer to conceptualize active addiction more like Acute Stress Disorder (ASD) because people are not typically in their right state of mind. It is similar to walking away from a car accident. People may be shaky, confused, disoriented, stunned, and/or limited in some way, but could return to a baseline if given enough time away from the event and the ability to make sense of it with their support system. Indeed, we are all “under the influence” of biochemical responses in the body and brain after a life-threatening event and any reintroduction to the stressor would bring us back to the event causing impairment if left unprocessed.

The body and brain know that it is in for a rollercoaster of a ride physically, psychologically, socially, and spiritually when a drug is taken because they remember it. Whether it is actual, perceived, medical, or existential; all drug use is replicating learned behaviors and threatens the life of the organism. The body acts accordingly to any threat or stressor (positive or negative) and each use, cue, or trigger acts as a reset for the body to return back to the original event.

So outpatients are treating the memory of active addiction, which is not an addiction by our diagnostic standard. For the most part, I would say that they are treating the echo of life events i.e. best conceptualized as trauma. However, many outpatients and residential settings are not using trauma therapies or at minimum trauma-informed care directly. They could start seeing better outcomes if they did.

Adam O’Brien LMHC, CASAC, EAS-C is the owner/clinician of Mutual Arising Mental Health Counseling, PLLC in rural Chatham NY. He works primarily with people suffering from their addictions but is also a trauma therapist working with victims of crime. In these freelance writings, he brings a variety of experiences and points of view to entertain and educate. He is currently becoming certified in EMDR and Progressive Counting and is aiming to support others by consulting and training. These blogs are to advocate for trauma services in the field of addiction but also serve as a way of reaching a wider audience.

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