Scott Kellogg, PhD and Andrew Tatarsky, PhD

The 2013 suicide of country singer Mindy McCready brought the death toll of patients who were treated on the reality TV show Celebrity Rehab to five. …. McCready’s death still calls for us to reflect more generally on the nature of addiction and its treatment. In addition, the loss of these five entertainers and public figures speaks to how devastating both addiction and mental illness remain as well as how our society conceives of addiction.

The DSM-V defines addictions to alcohol and drugs as psychiatric disorders. Nora Volkow, MD, the director of the National Institute on Drug Abuse, agrees, saying, “We need to first recognize that drug addiction is a mental illness.”

Our own approach to addiction treatment is based on the following assumptions:

• Addictions are psychiatric/mental health disorders.

• Many, if not most, people with serious substance use or addiction issues also have additional psychiatric issues such as PTSD, depression, anxiety disorders, psychosis, ADHD, and various personality disorders.

• With or without a diagnosable condition, people use substances for reasons that need to be respected and addressed.

• The treatment of addictions require professionals trained in mental health, skilled in psychotherapy, knowledgeable about the full range of psychological treatments, and fluent in the use of both addiction and psychiatric medications. Passion and dedication are important, but they do not make up for deep skill and knowledge.

What does a Humanistic Addiction Psychotherapy based on these assumptions look like? We believe that there are seven essential components:

1. Individual Psychotherapy: Each patient is unique and treatment must be individualized to address their specific needs, history, biology, pain, dreams and desires. While group experiences may be very powerful, even life changing, the integrity and depth of the individual psychotherapy session remains a uniquely curative experience—and the cornerstone of this approach.

2. Therapeutic Alliance: The connection between the patient and the therapist is of vital importance as it is at the heart of treatment. Good therapists will demonstrate love for their patients and will work with authenticity, optimism, courage and determination. Research in both addiction treatment and psychotherapy show the positive benefits of patients having a good relationship with their therapists.

3. Drug Use Is Meaningful: As noted earlier, people use substances for complex and deep-seated reasons that may need to be addressed before the individual will be willing to make changes in their use. Drugs may serve as a pathway to pleasure, as a way to reduce inner pain and suffering, as a method for coping with medical problems, as a vehicle for making and affirming social connection, and as a response to social oppression and poverty.

4. Multiplicity of Self: People who use drugs often have conflicting motivational forces at work—some of which support the continued use, others that fight for change. The motivations for change might include concerns about the family, anxiety related to economic or prestige threats, existential or spiritual concerns, health issues and legal problems. This inner conflict can be usefully re-conceptualized as a community of voices, modes, selves or parts. In this way, each of these energies can be respected and given a chance to speak, and dialogues can be created among the different parts to address their needs and desires.

5. Strengthening the Inner Leader: Identifying, connecting with and empowering the Inner Leader—sometimes called the healthy adult mode or the strong and healthy ego—can work to rebalance the inner forces. The individual can then make positive connections with others and take assertive, effective and meaningful action in the world. The Inner Leader of addicted patients is often underdeveloped or severely damaged, so strengthening it will remain an ongoing concern. To be clear, the healthy mode will be distinguished by its use of existential language such as “I want,” “I am deciding to,” “I am choosing to,” “I will,” “I say yes,” and “I say no”—rather than the use of phrases like “I have to,” “I need to,” and “I should.”

6. Working on Two Dimensions: Complex models of treatment, like Integrated Harm Reduction Psychotherapy, require therapists to work on two dimensions: both the use itself and the underlying pain and desires that drive it. Sometimes one will take precedence; sometimes both need to be addressed concurrently. Given this, it can be helpful to conceive of the work as involving both Horizontal and Vertical interventions.

Horizontal Interventions are techniques and strategies specifically focused on such issues as safer use, reduced use, moderation, nonaddictive use and abstinence, including Harm Reduction/Substance Use Management, Relapse Prevention and Contingency Management. The goal is to empower the patient to be able to control their use in a way that makes sense for them.

Vertical Interventions are those involved in treating the patient’s pain and underlying psychopathology. People wrestling with addictions may suffer from problems connected to the past (trauma, grief and moral failure), the present (depression, anxiety disorders, lack of assertiveness and personality disorders) or the future (life decisions, identity creation, the project of recovery and the need to embark on the Hero’s Journey). The therapist will want to be able to skillfully draw upon the full range of psychotherapeutic techniques to help the patient make connections, restructure cognitions, face feared experiences, work through traumas, mitigate the impact of the inner critic, claim power, clarify values, take heroic action, and learn to meditate and self-soothe.

7. Identity Transformation: While a great deal of addiction treatment is, understandably, focused on the present and the near future, long-term recovery depends on the ability of the individual to create and maintain identities that are viable, meaningful and reinforcing. The Addict Identity, which is central during active addiction, must be replaced with identities based on some connection to family, work, recovery, spirituality or other activities that provide a self-definition that is incompatible with problematic drug use. (For example, being a father takes precedence over using cocaine.) Most stories of successful recovery and life transformation involve some sort of identity reorganization or creation.

Tragically, Mindy McCready was ultimately overwhelmed and destroyed by the pain inside of her.

It is our hope that the leaders and practitioners in our field will embrace the future by working to fully integrate mental health and addiction treatment—both in the therapy we do and in the paradigms we create—so that we can understand and work with the complex interplay that exists between inner suffering and addictive behavior. Addiction is a mental illness.

This article was originally published in The Fix, February 27th, 2013; it has been slightly edited.

Scott Kellogg, PhD, is a former President of the Division on Addictions of the New York State Psychological Association and an ISST-Certified Advanced Schema Therapist. The Director of the Transformational Chairwork Psychotherapy Project and the Chairwork Psychotherapy Initiative, he can be reached at kelloggchairwork@gmail.com.

Andrew Tatarsky, PhD, is the author of Harm Reduction Psychotherapy: A New Treatment for Drug and Alcohol Problems. He was the founder of the Center for Optimal Living, an addiction treatment center in New York City, and he is the current Director of the Integrated Harm Reduction Training Program. His email is atatarskyphd@gmail.com.