Those who struggle with alcohol use can often feel a sense of alienation, deep self-loathing and shame, and in this world view it seems as if there are few trustworthy others to lean into for comfort. In intimate relationships this leads to disconnection, anger, disappointment, frustration, and chaos. Children growing up in households with active addiction often learn not to trust others. They are often anxious and insecure because their foundational base in childhood, the grown-ups they relied on for survival, safety, and security were either cruel, or confusingly unpredictable. One minute dad is the pied piper, beloved by all the neighborhood kids, the next a raging tyrant throwing things, chasing, yelling, terrifying. The same can hold true for mom. This reality can be present across all socioeconomic and educational strata because addiction doesn’t discriminate. Predicting which parent is showing up, the happy or intoxicated one, and how to avoid embarrassment or danger becomes a primary preoccupation of children growing up in such environments.
Alcohol, like any addictive substance, can take some time to settle in with its vise-like grip. Medical understanding for the underlying neurobiological change has offered hope and compassion in recognizing the physiologically determined power of denial and cravings. These are both pathognomonic features of addiction compared to simple unhealthy use. And denial can feel deceitful or confusing to the uneducated clinician while cravings can feel insurmountable to the struggling individual contributing to a potent negative synergy. Denial contributes to unfortunate interactions within the medical and mental health care systems, often serving as a barrier to much needed care. It is difficult to appreciate the power of cravings resulting in relapse without having ever experienced an unrelenting, irresistible want. Cravings fade with practice, skills, and a redefined life, but until they do managing this is a focus of early sobriety. Treatment is a stepwise process in detoxification, achieving and maintaining sobriety, self-understanding, skill building, and relationship repair. All of this work is an ongoing process while finding and defining new meaning and purpose in an expanding, rich emotional life.
Contemporary culture in the United States is immersed in alcohol. Prior to the pandemic alcohol had a solid grip on much of our social lives, our business interactions, our leisure, often our home life. But the pandemic accelerated use precipitously. When the governor of Colorado attempted to close liquor stores there was such an outcry that access to alcohol via delivery service was deemed essential. And so, the potent combination of isolation and easy access synergized with devastating results. Because of the complex changes in the brain with chronic exposure, it seems hopeless to individuals trapped in addiction. And escape demands a herculean, determined, and consistent effort, usually with a lot of help. Fortunately there is increased attention to a growing population of people actively seeking sober environments which are creatively expanding in response. Sober meet-ups, support groups, and communities continue to expand for those who have chosen not to drink, or are curious about a non-drinking lifestyle.
In intimate relationships already complicated by each bringing family of origin dynamics to bear (see my earlier post), alcohol further confuses expectations and communication. It also devastates an ability to be present and vulnerable for deeper connection. Couples are left wondering who is to blame, how much responsibility each holds for the crumbling relationship, and often there is anger, disappointment, frustration, and distrust. While it isn’t hopeless, there is a lot of work to be done in climbing out. Individual, couples, and group therapy each offer different benefits, challenges, and perspectives in multiple settings. But safe detoxification is a priority, and the approach is determined by medical parameters defined by a vast experience. Withdrawal seizures and the delirium tremens or DT’s can both be fatal in a setting of long-term severe alcohol use disorder which is specifically defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM) published and periodically updated by the American Psychiatric Association. And so, assessment is the first order of business to formulate a safe and collaborative plan. Once safely through detoxification, the work of achieving sobriety can begin in inpatient, residential, partial hospitalization, or outpatient practice settings. Criteria for appropriate treatment settings is one of the subjects of the American Society of Addiction Medicine’s (ASAM) discipline. And early sobriety begins the work of unwinding years of numbing, avoiding, and often a substantial trauma burden. Regaining trust in self and others, facing the impacts of addiction, rebuilding relationships, and learning to navigate emotions while building a new life in the face of frequent cravings, is no small feat.
Individual therapy is a place to gradually reveal increasingly vulnerable questions and experiences; how did I get here? Often leading to a feeling of coming out of the matrix, many learn that their families growing up were not healthy. They learn that being disregarded and dismissed, neglected, physically, emotionally, sexually abused, was not their fault, that they could not have changed a thing, and that they are not broken so much as adapted to unhealthy relating. Coping mechanisms developed in childhood are deeply rooted and it takes time to recognize where these show up before being able to consider a different approach. A gradually expanding point of view to explore intergenerational experience can lead to both confusion and revelation. This is some of the work of therapy, learning to trust while deconstructing a long-held world view, and learning to be in the world in a vastly different way. It can be grueling, but also profoundly rewarding. And there are also moments of wonder, as hard as it is it isn’t all bad. Building a new life can have moments of exhilaration, peace, and joy too.
Couples work engaged in tackling substance use brings with it the challenges of family of origin dynamics additionally suffused with the anger, distrust, and disappointment of out-of-control substance use. Feelings of betrayal and bewilderment by the sober partner must be engaged and validated, while also engaging the deep trauma of the partner struggling to detach from the neurobiology of addiction. And in all of this, consistently reflecting hard truths while facilitating empathy in the partners for each other, must be held in steady focus. Additionally, physical and emotional boundaries must often be constructed from the ground up while each works to understand what is happening, what has happened, what the future looks like. The therapist holds possibility, in addition to the required frame of consistency, reliability, safety, for increased intimacy or dissolution of the relationship. There must be tolerance for ambiguity, ambivalence, and uncertainty as well as emotional turbulence.
The person who crosses the threshold of addiction to the other side has learned profound truths about self and relationship and about the world, and sobriety is achievable after addiction. Many people struggling with alcohol and other substances manage to stop on their own. But often additional help, support, and guidance are necessary. There are a multitude of supportive groups, peer and professionally led. If one reaches end stage liver disease (ESLD) however, a much bigger process is involved. Click the link below for an in-depth review of alcohol use disorder and liver transplant, one of the most effortful treatments which can be life saving. Because learning about your addiction can be a confusing and disorienting process please reach out to make an appointment for more information, assessment, and treatment. Stay tuned for more information. Knowledge is power and I appreciate you.