The behavioral healthcare field is currently going through a period of transition – a time of increasing emphasis on the use of integrative approaches in the treatment of substance use and mental health problems. This change is not only being driven by economic necessity, but also by innovations in clinical practice. For this effort to be successful, however, we will want to have therapeutic models and philosophies that not only help us to better conceptualize the relationship between drug use and inner suffering, but also effectively guide us in our clinical work. Gradualism, I believe, is a paradigm that can serve this purpose.
As the name would imply, Gradualism is a clinical paradigm that conceptualizes addictions as complex behaviors and understands that, for many, the process of healing and change will take place over an extended period of time. First formalized in 2001 (Kellogg, 2003; Kellogg & Kreek, 2005), Gradualism was an attempt to “utilize and integrate the best of the harm reduction, traditional, and scientific treatment approaches to create an effective and compassionate model” of addiction treatment.
Working to creating a treatment structure appropriate to this clinical philosophy, I began to explore what I have come to think of as the Mechanisms of Change Project (Kellogg & Tatarsky, 2010, 2012). Drawing on what I have learned from these two efforts, I believe that there are four clinical concepts that can usefully guide clinicians who wish to work within an integrated model of care.
1. Drug use and inner pain are the experiences of individuals and treatment should reflect this.
While the psychotherapeutic traditions have certainly emphasized the centrality of individual treatment, this has not been the standard in addiction care. As both research and clinical practice have shown, a strong and viable therapeutic alliance is at the heart of successful treatment. This means that the promotion and maintenance of this kind of connection should be an essential concern of both individual clinicians and the treatment systems in which they work. Along these lines, each patient comes to treatment with a unique psychological make-up, genetic profile, medical background, motivational state, and drug history – which means that treatment planning that is uniquely conceived for the patient should be the norm.
2. Drug use is both complex and meaningful.
The understanding that drug use is a multiply-determined behavior connects us to the Self Medication Hypothesis of Dr. Edward Khantzian (1985) and the Integrative Harm Reduction Psychotherapy model of Dr. Andrew Tatarsky (Tatarsky, 2002; Tatarsky & Kellogg, 2012). In essence, it means that people use substances in problematic ways for reasons – reasons that need to be understood, respected, and, at times, treated directly. Importantly, some patients will not be willing to alter their substance use patterns until this work is done.
For example, a woman in a drop-in center said, “I’ve always felt like I wanted to die since I was a little kid. I don’t know why… I want to see a therapist or psychiatrist about it but I don’t go ‘cause I’m afraid to tell them I still do dope. I still just really love to get high.” (Welch, 2011). The dilemma facing this woman is that she is both troubled by some kind inner pain and still very invested in the use of opiates. What she wants is a clinician or a clinical setting that can “hold” both of these realities while helping her sort through them. She believes, however, that if she goes to see a professional, she will immediately be told to stop using substances before getting a chance to successfully do this. The result is that she stays away from treatment. Unfortunately, her assessment of the situation is probably correct.
Looking at this more broadly, the reasons that people use drugs and alcohol in addictive or problematic ways can be organized, for the most part, into two categories. The first is pleasure. The hedonic qualities of drug use may come from their ability to connect people to experiences of pleasure, creativity, joy, and a sense of being alive. For some, these may be states that they find to be quite difficult to access without the use of substances. Drugs may also allow individuals to connect to others more readily and/or to become members of desired groups or subcultures. The second reason, as we have seen, is that they reduce inner pain and suffering. The self-medication properties of drugs may, at least temporarily, alleviate psychiatric symptoms, quell drug-induced, neurobiological changes, and/or reduce pain connected to medical illnesses.
In turn, the motivation to change is often driven by fear and desire. The fear may be based on the growing realization that continued drug use will (a) have detrimental effects on family, children, and other significant relationships; (b) lead to job loss, prevent career advancement, or jeopardize a professional license; (c) threaten an individual’s freedom; and/or (d) damage their health in serious ways or lead to their death. The desire for something better may include spiritual or existential experiences or profound moments when the individual comes to the realization that there is something more important that he or she could be doing with his or her life. All four of these motivations will play a role in depth-oriented work.
As a way of operationalizing these ideas, it is very useful to conceptualize the internal world of patients using models of Multiplicity of Self. This means that patients are not seen in a unitary fashion; instead, they are seen as containing a number of different selves, modes, or parts – each of which may be active in different situations and for varying lengths of time (Rafaeli, Bernstein, & Young, 2011). This, of course, is not a new idea in the culture of addiction as many people make reference to Dr. Jekyll and Mr. Hyde (Stevenson, 1967) when they speak about their struggles with drugs. From a clinical perspective, the Jekyll and Hyde reference is not particularly accurate as it fails to capture the reality of inner suffering. Nonetheless, it does provide a therapeutic entrée for working with ideas of personal complexity (Kellogg & Tatarsky, 2012).
In practice, these forces can often be identified using the Decisional Balance technique (Marlatt & Gordon, 1985) – a therapeutic process in which the patient is asked to identify the positive and negative aspects of the drug use and the perceived positive and negative aspects of making a change. The work then involves first giving voice to the different parts and then working to understand what they want and need. Attempts are then made to address the needs of those parts that are in pain so that they do not have to turn to substances; efforts are also made to empower the healthy parts and help them find expression in the world.
3. Integrated treatment involves addressing both the underlying pain and the drug use itself.
While problematic substance use may have its origin in one or more of these factors and while these forces may continue to play a role throughout the using career, addictions have their own dynamic and momentum. Working with the underlying causes is sometimes not enough; the drug use must also be addressed directly. Given these complexities, it is important for clinicians to have the skills and mastery to work on two dimensions – the Horizontal and the Vertical. The horizontal interventions are those that are concerned with helping patients alter, reduce, or cease their use of substances. These include Substance Use Management, Relapse Prevention, and Contingency Management or the use of positive reinforcement systems. The vertical, in turn, are focused on addressing and treating the underlying pain, suffering, and psychopathology; these include the full range of relational, cognitive, behavioral, experiential, existential, and mindfulness-based interventions.
In a related vein, many patients who wrestle with addictions, psychological difficulties, or both report being plagued by experiences of self-hatred or self-attack. Often referred to as an inner critic, these experiences drive both the emotional suffering (i.e., depression and anxiety) and the problematic behaviors that patients use to cope with it (i.e., self-harm, rituals, and addictions) (Rafaeli et al., 2011; Tatarsky & Kellogg, 2011; Wurmser, 1978). The internal world of these patients is typically out of balance, and the internal leader, healthy self, or ego is often not strong enough to combat the critic, soothe the suffering parts, or lead the system. This, then, becomes a central focus of the therapy. In my clinical work, I have found the Gestalt Chairwork technique to be a strikingly effectively method for doing this kind of work (Kellogg, 2004; Perls, 1969).
The therapy, then, involves working on both dimensions – sometimes focusing on the drug use, sometimes working with the pain, and sometimes working with both simultaneously. Again, this approach acknowledges that while some patients may make dramatic life changes, slow and gradual progress may be the norm for many others.
4. Long-term, successful recovery involves the creation of meaningful and rewarding identities that can compete with and replace those based on the use of drugs.
One way of understanding addiction is to see it as an experience in which the Addict Identity has become a central and defining identity in the person’s role hierarchy. Successful long-term healing and recovery takes place when identities based on work, family, recovery, athletics, spirituality, or some other form of group connectedness or activity compete with and replace those based on the drug and alcohol use.
This was brought home to me early in my career in my work with a woman I will call Natalie. A patient in a methadone clinic who had a history of heroin use, Natalie revealed to me one day that she had never used heroin intravenously – only subcutaneously or intramuscularly. This was certainly very unusual behavior for patients in that kind of setting. As we explored it further, she revealed that being a mother to her two daughters was so important to her that it had, in face, impacted on her heroin use. She felt that “shooting” heroin would be so dangerous to her role and identity to as a mother that she refused to take that “final” step that so many others had taken. In fact, it was her love for her children had led her to join the methadone program in the first place. Natalie did quite well in treatment, started to attend college, went through a dose-reduction process, and completed treatment – all for the sake of her two little girls. While a very unusual story, it does show the power of identity in the processes of change, healing, and recovery. Most stories of long-term abstinence and moderation embody these kinds of identity transformations (Biernacki, 1986; Kellogg, 1993).
With the move toward integrative care, I believe that the insights and strategies of Gradualism can be both empowering to therapists and curative for patients. Those who are suffering from addictions need treatments that are driven by compassion, creativity, and science. It is with this spirit that I hope we will embrace the future.
Scott Kellogg, PhD, is the former President of the Division on Addictions of the New York State Psychological Association, a Certified Schema Therapist, and a Clinical Assistant Professor in the New York University Department of Psychology. He has a private practice at The Chairwork/Schema Therapy Treatment Project. His websites are www.gradualismandaddiction.org and www.transformationalchairwork.com. Dr. Kellogg can be reached at: scott.kellogg@nyu.edu. All references contained in this article are available on request.
