Addiction involves a complex array of factors: genetic, biological, social, environmental, and intrapsychic which all have a role to play.  Due to this complexity, getting sober is only the beginning of the path toward recovery from addiction.  This difficult process is complicated further by the power of conditioned associations (Sideroff, 1980).  Anything that was connected with the addictive process can take on power through these associations, triggering craving or a conditioned abstinence reaction. Life for the recovering addict is an obstacle course filled with landmines, the dangers of which are increased by the interactional process of life stresses and the addict’s stress response.

Stress is ubiquitous in one’s life.  For most addicts, substance use has become the primary coping mechanism for dealing with life’s challenges.  In many cases, the addictive process itself, is the consequence of an attempt at self-medication partly due to one’s inadequate ability to cope with stress.

For these reasons, the recovery process is very tenuous, as demonstrated by the high rates of relapse (SAMSHA, 2004).   One’s coping abilities are constantly challenged.  Stress can be a primary triggering factor that leaves the abstinent addict vulnerable.  Research has demonstrated that addicts who are exposed to stress are more at risk for relapse (Sinha, R 2007, 2008). Early trauma and stress can actually sensitize the brain to the exaggerated release of dopamine thereby triggering craving (Piazza PV, and Le Moal M, 1996). Stress, in other words, triggers brain mechanisms of craving.

Washton (1989) has described a typical chain of events that leads to relapse starting with a buildup of stress.  In this model, typical life events and challenges, both negative and positive, create stress that is then magnified by the addict’s thought process.  Due to their difficulty tolerating affect there will be either a failure to act or an over reaction.  This process perpetuates stressful situations.  The addict enters a vicious cycle, first by denying the seriousness of the problem, then by failing to use existing tools of recovery.

A partial or full withdrawal from therapy or participation in meetings leads to a further increase in stress and additional emotional pressure and activation.  The cycle continues with further regression both in the ability to use coping mechanisms as well as in self-efficacy.  The abstinent addict falls back on maladaptive solutions and cravings increase along with drug preoccupation, which is the addict’s ultimate default solution to discomfort.  Continued disconnect from support systems, frustration, despair and the obsessive preoccupation with drug related thoughts leads to irresistible craving and ultimately renewed drug use.

From a neurobiological perspective, what appears to be happening is an increase in the release of dopamine in the brain, specifically being sent to the Nucleus Acumbens (NA).  Here the brain engages in a process of assessment of need that drives behavior.  With an increase of dopamine, there is an increase in organismic discomfort and danger.  This is typically accompanied by a drop in Serotonin levels, which is the neurotransmitter associated with comfort and satiation.  This neurotransmitter imbalance triggers more focused reward seeking behavior, where nothing else matters other than getting the drug.

What this scenario highlights is that the recovering addict is rendered less effective and more emotional by the common stresses of life.  This reactivity tends to weaken whatever coping skills they have learned, and they fall back on familiar, ingrained drug-seeking behavior.  Furthermore, this process is progressive and regressive, causing an accelerated deterioration. The addict cannot recover or bounce back from adversity.

Life itself is stressful.  However, a person who has recently become sober is typically faced with a much larger scale of stresses.  I’m reminded of what an ex-addict once told me.  He said addiction is like a person driving in a station wagon and throwing all their bills and unfinished business into the back of the car.  Sobriety is like hitting the brakes and having everything from the back of the station wagon hurl forward into your lap.  Programs designed to help the addict become more resilient can make them less vulnerable to the decompensating impact of life stresses.

Consequently, this paper – presented in three installments – specifically focuses on my comprehensive nine-component model of resilience (Sideroff 2004).  It is a systematic approach to personal efficacy and enhanced coping skills in dealing with stress.  In this presentation, I have adapted this model to address the web of factors faced by the addict in the recovery process.   Through a focus on each of my components of resilience, and taking steps to enhance one’s ability along these dimensions, a recovering addict can better navigate the obstacle course of abstinence.

My model divides these nine components into three areas:  relationship, organismic balance and mastery, and process.  Within relationship there is “relationship with self”, “relationship with others”, and “relationship with something greater”.  Organismic balance and mastery is divided into physical, emotional and mental.  Process includes presence, flexibility and power (which I define as the ability to get things done).  In the remainder of this paper, I will address the three components within relationship.

Relationship with Self;  Component #1:

In our therapeutic relationships we teach, encourage, support and guide.  But no matter what we do, or how hard our clients try, no approach can compete with the incessant voice in the addict’s head.  Logic rarely wins in the competition with this voice’s evaluation of what “feels right”.

Another way of framing our internal dialogue is to refer to it as a dialogue between us and our internal parent.  This is at the heart of our relationship with our selves.  This aspect of our intrapsychic architecture is the result of our developmental history.  I have elucidated this neurodevelopmental process in my concept of Primitive Gestalts in a previous paper (Sideroff, 2005).  A Primitive Gestalt (PG) is the neurobiological patterning imprinted during early childhood development.  It is the result of our learned survival mechanisms in our interactions with our primary caregiver(s).  The main components of this PG include a world view, including our expectations of how the world functions, our view of others, and our view and evaluation of ourselves.  We can consider our internal parent to be the voice of our PG..

Our internal parent is thus a product of modeling our caregiver’s behavior; how they treated us, how they acted toward themselves and the world, and their judgments about us.  Is the world basically hostile or friendly?  Is it abundant or based on scarcity?  Is it predictable or arbitrary?  Am I okay or defective?  Do you expect negative or positive outcomes (e.g. will I be accepted or rejected)?  The answers to these questions determine how often our stress response gets triggered: the more negative our outlook, and self-talk, the more danger and uncertainty we experience.  The more critical the self-evaluation of our internal parent, the more fearful and less confident we are, and thus the more our stress response gets triggered.

One consequence of this imprinted internal parent is that its filtering or evaluation mechanism interferes with healthy redevelopment, since what “feels right” is whatever is in alignment with this imprinted filter.  In other words, the client’s process of internalizing new information must go through this filter.  The assessment’s feeling component will consistently override logic.  In other words, the good and useful information presented during therapy or a treatment program will frequently not pass the “feels right” test that determines psychic incorporation!

The first and perhaps most important component of resilience within addiction therefore, is addressing one’s relationship with him- or herself – with their internal voice or parent.  Unless this is addressed, there is a tendency for self-sabotage and resistance to the recovery process.  Relationship with self is, very simply, how you treat yourself, how you talk to yourself and how you value yourself.  If we analyze all of our behavior, it starts with our self-talk and the messages we give ourselves.  This is backed up by the self-talk that occurs following the behavior or actions we take.  How we handle mistakes, whether we are critical or supportive, as well as how we appropriately take in our accomplishments will determine our developmental and healing trajectory.

Process for improving your relationship to yourself

1. The first step is the assessment of your existing internal parent, facilitated by asking a few questions:  “Is your internal parent supportive or does it more often find fault?” “Does he/she focus on what you did right, or what you did wrong?” “Is he/she accepting or critical?”  Homework for this step is to engage in a process I refer to as “stalking your pattern”.  This assignment is to pay attention, as a neutral witness, to how your internal parent talks to you.
2. Next is the process of helping the addict client independently determine what a healthy parent looks like, sounds like, and acts like.  Here the process would be to identify a person in their lives who fits the qualities of a good parent.  With some clients it might even be themselves – how they treat their own child.  With others it might be a grandparent, or an aunt or uncle.  With some clients, they may have to turn to a person in literature or the movies who exemplifies the ideals of a good parent.  In any case, this step is about establishing an objective model and identifying the qualities that can be used for comparison and learning.
3. The next step is engaging in a gestalt process of dialogue between these two voices.  One problem with addressing the abusive internal parent is that it is always there inside of us and thus “feels right”, like it belongs to and is a part of the client.  Creating a dialogue between their internal parent and the newly conceived healthy parent allows the client to form a separation from that voice, perhaps for the first time.  It also begins to create a countervailing force to be nurtured and strengthened.
4. The next part of the process is to help the addict client recognize that their internal parent was formed and adapted to their early dysfunctional environment.  Even though it feels like it’s a part of their DNA, it is actually a learned position.  As such, it is possible to develop a healthy and loving internal parent.  This is the step of creating possibilities.

The process aims to help the addict client independently determine what a healthy parent looks like, and how that healthy parent thinks and behaves.  The addict client stalks their pattern and begins recognizing its ongoing influence, all the while remembering to acknowledge what a healthy internal parent would think and say.

Relationship with others; Component #2:

One’s relationship with others is the second component of resilience.  Here we are talking about one’s ability and willingness to establish and maintain healthy relationships that are sources of support, acceptance, love and healthy feedback.  This means being able to identify appropriate people for a healthy relationship and letting go of those who do not treat you well or support you.  It means being able to, on the one hand, maintain a healthy boundary for protection, while on the other hand being assertive to get your needs met.  And finally, it means to allow oneself to let down one’s guard under the right circumstances, being vulnerable in order to go to the deepest places of nurturing and healing.

We can consider resilience in terms of efficient and effective behaviors and approaches to life.  “Efficient” refers to the optimal management of one’s energy and efforts, making the most of what you have, and expending only that amount of energy necessary.  If you don’t trust your close relationships, then you are wasting energy being on-guard and tense, while not offering the opportunity for nurturing and acceptance.  Conflictual relationships are also a source of stress, creating unfinished business that leaves you drained.  In a sense, just as you want to make sure that your internal parent is accepting and supportive, you want these same qualities in your relationships with others.

Process for improving your relationship with others:

1. Start off by asking these questions:  do your relationships make life more or less stressful?  Is the feedback you get helpful and supportive, or critical and inappropriate?  Do your friends or relatives make unreasonable demands or make you feel guilty, adding stress to your life?  Do your friends think only of themselves?  The other side of the equation is whether you are able to say “no”, and set necessary boundaries.  Do you feel like you are walking on egg-shells with some of your friends or relatives?  Are you fearful of their anger or of being rejected?
2. Establish an anchor, or reference point for appropriate expectations and boundary setting. When a client is having difficulty recognizing what is right or wrong for themselves, they can find the answer more easily if they imagine the same situation happening either to a friend, or their child.  They are able to be more objective and caring when they aren’t directly involved.
3. Role playing: again, using gestalt therapeutic techniques one can play the client and have the client play their friend, relative, business partner, etc.  This serves to model the appropriate behaviors.

John Gottman, a psychologist who works extensively with couples, has found that successful relationships have a five to one ratio of positive to negative interactions.  When a client is questioning one of their relationships, I’ll ask them to pay attention to their positive to negative ratio.  The simple process of noticing will have a powerful influence on either shifting the relationship or ending it.

Relationship with something greater; component #3:

Spirituality has always been an important component of treating addictions.  The foundation of the twelve-step programs is turning your life over to God.  Component three, relationship with something greater, refers to connection, spiritual belief, and creating meaning in one’s life.  Again, from the perspective of becoming resilient and more able to handle the stresses of life, a belief in a power beyond oneself offers comfort, security and reassurance.  Having a purpose in life expands one’s emotional perceptual horizons.  Each daily hassle and bump in the road has less impact, when one has a larger perspective, a focus beyond one’s own small world.

If we are talking about one’s internal parent, or our relationship with others, we start off with the concerns that these relationships might be stressful and unsupportive.  It is very likely that the internal parent has some abusive qualities which are also issues with friends and relatives.  However, when we refer to a higher power, it is easier to establish a loving and supportive image and concept with which to relate.

Establishing a purpose and meaning to one’s life serves many functions in the service of resilience.  There is less self-preoccupation, and thus less of a focus on one’s own problems and pains.  It also has the potential of enhancing one’s sense of personal value and giving direction and service.  These factors begin to balance out an addict’s guilt and regrets.  They help in the process of allowing the client to sleep better at night.

Process for enhancing your relationship with something greater:

The 12 step programs are a built-in mechanism for nurturing this component of resilience.  It is helpful to explain to the addict client how their spiritual beliefs or the development of a purpose in their lives fits in with this overall concept of resilience and how it can help them manage the daily frustrations that they encounter.  Part of this process is to show them how to use their spiritual practice, and to help them reference it during their most difficult times.

Once they identify a purpose or a cause that they can give service to, it is important to help the client addict “accept” or take in these positive behaviors.  These are sources of what I consider to be emotional nourishment, but it is important to make sure the client does not find some way of dismissing these efforts.

References

Piazza PV, Le Moal M. Pathophysiological basis of vulnerability to drug abuse: Role of an interaction between stress, glucocorticoids and dopaminergic neurons. Ann Rev Pharm Tox 36:359-78, 1996.
Sideroff, S. and Jarvik, M.E., Conditioned responses to a videotape showing heroin-related stimuli. Int. J. Addict. 15(4):529-536, 1980.

Sideroff, Stephen I.  Resilience: A functional approach to stress.  California Biofeedback 20(1): 5,12-14, Spring 2004.

Sideroff, Stephen I. Primitive Gestalts: Early developmental patterns and their effect on later life.  Somatics, 15(1): 10-17, Fall/Winter 2004-2005.

Sinha R. (2007). The role of stress in addiction relapse. Current Psychiatry Reports, Vol 9(5),388-395

Sinha, R. (2008). Chronic stress, drug use and vulnerability to addiction. Annals of the New York Academy of Sciences: Addiction Reviews, Vol. 1141, 105-130

Substance Abuse and Mental Health Services Administration. (2004). Results from the 2003 National  Survey on Drug use and Health (Office of Applied Studies, NSDUH Series H-25). Rockville, MD

Washton, A. M. Structured outpatient treatment of alcohol vs. drug dependencies. In Galanter M (Ed.) Annual Review of Alcoholism, pp. 265-304, New York: Plenum, 1989.