[Abuse in Psychological Perspective
— meeting the person behind the intoxication]
Misbrug i psykologisk perspektiv
— mødet med mennesket bag rusen
Dansk Psykologisk Forlag
[Danish Psychological Publisher]
First, I was going to write these pages in Danish, the language in which the book Abuse in Psychological Perspective — meeting the person behind the intoxication was just published. Then, on second thought, seeing the book is already getting multiple reviews in Danish, a mention in English might make more sense. Who knows, maybe somebody out there will want to translate it. The book’s content is a worthy contribution and its subject — abuse — affects nigh near all human societies.
Here are the book’s six chapters with their respective authors:
“Afhængigheds logik” (The Logic of Dependence), by Helle Kjær
“Faglig medmenneskelighed” (Professional Humanity), also by Helle Kjær
“Mødet med voksne” (Meeting Adults), by Eric Allouche
”Unge og overforbrug af rusmidler” (Youth and Substance Excess), by Charlotte Silas Houlberg
”Psykiske lidelser og rusmiddelmisbrug” (Mental Illness and Substance Abuse), by Birgitte Thylstrup
”Pårørende” (Next of Kin), by Helle Lindgaard
The book is about the people for whom abuse is part of their lives, as well as about the people whose job it is to help/treat those suffering the destructive effects of abuse. Where abuse is concerned, the book is fittingly centered on substance abuse (drugs, alcohol). I write “fittingly” because alcohol abuse is widespread in Denmark. Young people in Denmark beat young people just about everywhere else when it comes to alcohol consumption. It doesn’t mean that the book is primarily of interest for Danes. The expertise developed here may serve elsewhere, particularly as it may usefully be tailored to other types of abuses that generously fill the news: sexual abuse, physical and mental abuse, abuse of power, environmental abuse, financial abuse, not to mention the broad swath of abuses intensively playing out these days in Russia’s war against Ukraine, as well as in other conflicts. Seen thus, the far-reaching consequences of abuse in its many forms cannot be overstated, for the individual, for the family, and for society at large.
The originality of the book is that it is written by five experienced professionals who tone down (but do not disregard) diagnostics, methodology, and evidence-based considerations. During the 19th, 20th and now 21st centuries, a great deal of formal knowledge has been accumulated on various aspects of substance abuse: mental and physical symptomatology, various patterns of alcoholism and types of intoxication, distribution in society, behavior, diagnostics, the short-term and long-term consequences for physical and mental health, methods of treatment. Much of this information is readily available, starting with Eugen Bleuler’s classic Lehrbuch der Psychiatrie (textbook of psychiatry first published in 1916 and still going strong). Our five authors do not dwell on all these details but focus on the people and relations behind the abuse: clients/patients (or brugere, as they are called in Danish, i.e., users), family, friends, colleagues, as well as the care-giving professionals themselves. Furthermore, the authors — though professional psychologists, psychoanalysts, researchers, directors and chairmen of abuse treatment institutions and societies — have gone out of their way to write a book accessible to a wide public: other professionals in health and social fields, members of the police force, personnel in schools as well as in other institutions of learning, not to forget abusers and kins. The authors are addressing the entire network of people in and around abuse. The book is short (150 pages) and to the point. Still, straddling such a broad public is not without hurdles.
Abuse is not simply a personal or biological issue, it is also a relational and societal issue. You’d think there would be nothing contentious today about saying so. Still, there was an interesting disagreement on where to put the accent in choosing the title of the book. I was at the reception marking the book’s publication at the University of Aarhus campus in Copenhagen where professionals and patients mingled. The five authors gave talks on the book’s making and content. The authors would have liked for the book NOT to be called Abuse in Psychological Perspective — meeting the person behind the intoxication as is the case, but instead Meeting the person behind the intoxication — abuse in psychological perspective (in Danish: Mødet med mennesket bag rusen — misbrug i psykologisk perspektiv). In other words, the authors would have inverted title and subtitle, setting people first and abuse second. The Danish Psychological Publisher did not see it that way, perhaps because of their professional, academic clientele. In any case, the publisher having the final say, the arresting word “abuse” comes first.
The authors would also have liked a bouquet of flowers on the book’s cover instead of the many arrows pointing in all directions you see on the actual cover. Here's one from me to them:
Perhaps the publisher’s priorities also explain why the book’s introduction and first two chapters seem to paradoxically prioritize theory and clinical research/background over people. Still, the reader is given the opportunity to familiarize herself with ideas, experiences, and references that shape the authors’ take on peoples’ dependence on substances that often lead to destructive and self-destructive abuse. For the readers who find these chapters a little too academic, they can skip them and go straight to the person-centered chapters on meeting adults and youths with substance abuse, as well as the final chapter on next of kin (chapters 3, 4 and 6). After having read these chapters, the non-academic reader will probably be more motivated to read the other three. With the knowledge that even experienced professionals can sometimes have difficulty distinguishing between what is evidence-based, experience-based, and fictional clichés, readers will hopefully have more patience to ponder the crucial importance of how all three of these dimensions each have their areas of validity: evidence, experience, and fiction.
Pe0ple Are More than the Sum of Their Problems
A key idea in the book, stated from the outset, is that a human being is other and more than its problems. Preconceptions of “the typical addict” (e.g., the drunkard, the prostitute, the vagrant, but also the privileged housewife taking to the bottle and the heroin-addicted CEO) are unhelpful, simplified and simplifying fantasies. Professionals will meet their clients in their broader, unique, human complexity, thereby opening more individualized avenues for harm-reducing treatments and motivational talks. “Other and more than the problems” refers not only to the resources an individual may have independently of abuse, but also to the vulnerabilities that make the use of chemical substances tempting. Often, at the beginning, abuse helps make difficult situations more tolerable. Later, when abuse has started taking its toll, adversely affecting a person’s health, cognitive and emotional intelligence, as well as the interrelatedness of all three, ambivalence about giving up abuse may be strong, even with a manifest wish to undergo therapy. Clients know what they have (abuse) but are not sure what they’ll get. There is a kind of security in abuse. Will the effort needed to break the habit lead to something better? The ride may be rough, both for the patient and the therapist, with moments of hopelessness, stress, and provocation. Both may need support during the process, the patient from his social network and supervision for the therapist.
Shame, guilt, as well feelings of worthlessness loom large in the lives of addicts and close family and friends exposed to addiction. In Denmark, only a fraction of the people suffering from alcohol abuse seek help, let alone treatment. Note that this is so despite Danish legislation ensuring anonymous and free treatment for all substance abusers. Imagine what it’s like elsewhere in the world. The problem is compounded because substance abuse has a particularly bad reputation among mental disorders. There is a tendency to moralize, to stigmatize, to think that abuse is a matter of willpower (or lack thereof). Instead, the person seeking help (and courageous enough to do so) is best served being met with respect, steering clear of triggers to shame and guilt, focusing on social interaction, between client and therapist and beyond.
Social interaction is paramount; it is more important than the heroin high. It is not without humor that we are reminded in the book of scientific experiments with rats and heroin. First, it was shown that a rat alone in a cage would become addicted to heroin from a readily available source. Later, another experiment showed that given the choice, rats preferred interaction with other rats to heroin, even when heroin was readily available. Placing scientific results in context makes a big difference. In the first case, we are led to focus on the destructively addictive power of heroin. In the second case, we discover social interaction can make heroin uninteresting. In this regard, human beings are probably not very different from rats, fortunately. Neither brains nor emotions work in isolation. They thrive on interaction with the brains and emotions of others. As Johan Hari writes: “The opposite of addiction isn’t sobriety, it’s connection.”
The question is how to connect or re-connect people suffering from abuse. And to what kind of social interaction, remembering that there is lot of abusive and destructive social interaction out there. In writing “remembering,” I’m thinking primarily of professionals since many people suffering from substance abuse are all too familiar with destructive social interaction. Many have been traumatized into abuse by it and are at a loss for words with which to navigate their lives.
Two particularities of our present-day world increase the difficulty of the task. Modern human beings are often unable to establish an identity and a relatedness to others, a problem that seems to be getting worse and that the Danish philosopher Søren Kierkegaard already pointed out using other words in Sygdommen til Døden (Sickness unto Death, 1849); either you identify with God or you despair and lose yourself. Another backdrop to our modern lives is the temptation of the quick fix, a type of satisfaction that denies the possibility of desire. Why? Because there is no desire without some kind of renunciation and the quick fix does not allow for either renunciation or the affirmation of desire through sublimation.
The Rock Star and the Psychoanalyst
Let me give you an example from my own life. When my children were in middle school, it became clear that alcohol consumption was becoming a potential problem. Through the years, a number of PTA meetings were devoted to the matter. We — parents and teachers — had some good talks (sometimes with our children too) and set up a number of rules for our children to follow when they socialized. I remember one meeting in particular where one of the other parents, a famous multitalented guitarist, remarked that he thought we were greatly exaggerating the problem, “let them do their thing, they’ll grow out of it.” To which I commented: “Well, it seems to have worked out for you, Mik. That’s because you’ve got your guitars and the place they have in your life. You seem to forget that our kids haven’t found theirs yet and that it doesn’t just happen automatically and even when it does, it doesn’t necessarily protect you from abuse. That’s where we have a role to play.”
The Danish cover of the pamphlet above says: "Information to parents... Children and the young drink more than you think. It's your responsibility to set limits." Below it is a photograph of a Gibson Firebird.
A Shared Project, True and Authentic
In several of Abuse’s chapters, emphasis is put on establishing a shared project between professionals and users/patients/clients. Already examination and screening should be conducted as a project in common. The attitude of professionals is also discussed. Being a mirror for patients or insisting on hidden meanings or on the interpretation of traumas is not the way to go with substance abusers, at least not at the beginning. Forging a healthier present social bond is more important, as is patience for the long haul, which can be a challenge. The importance for professionals to be true and authentic is likewise discussed and described through examples.
The Young, Abuse and Psychiatry
A chapter in the book puts specific focus on the young, immediately followed by a chapter centered on the relationship between substance abuse and mental illness. The reciprocal proximity of the two chapters is no coincidence. Here, several themes are explored. Attention is drawn to the importance of establishing offers specifically tailored to the young, where brain and body are still under construction and where childhood, family and school play a more direct role than for adults.
I found the discussion of the intimate relationship between mental illness and substance abuse particularly interesting. Some young abusers have double diagnoses, one related to substance abuse and one or more related to mental illness. (Sometimes the problem is further complicated by criminal activity.) Not a few have given up using words to speak about things that are difficult in life or even just to navigate their lives with (see above). Substance abuse fills that space, sometimes with more symptom-producing variants of drugs than were previously on the market, e.g., the more powerful THC cannabis instead of the milder CBD cannabis.
The book’s authors draw attention to a dilemma in Denmark (for all its welfare), namely the disconnect between drug treatment offers and psychiatric treatment offers for mental illness, something particularly detrimental to the young.
There are good examples of the advantages of creating safe therapeutic spaces where the young can speak about their abuse, find words with which to express and explore life’s difficulties, sometimes allowing mental problems (e.g., paranoid thoughts) to surface in ways that make them more amenable to processing. Similarly, when it comes to the provocations some young people are wont to practice, provocations that irritate and exasperate many. The book’s sound advice to professionals here is to turn the provocation into a question that can be explored: Why is it so important to provoke?
Next of Kin
The previous questions fine effortlessly away into the book’s final chapter on next of kin to persons (young and old) whose lives are marked by substance abuse. “Often being next of kin means being confronted with dilemmas with no unequivocal solution in sight. Consequently, next of kin are prone to stay on the rollercoaster all too long.” At the same time — as the book’s emphasis on social interaction already has suggested — next of kin are a key element in both substance abuse and its resolution.
The chapter reviews the stress, secrecy, shame, embarrassment, and depression experienced by next of kin. Focus is successively on couples, families, parents, and children. System theory is the author’s guide, stressing the importance of including next of kin in the treatment process. Abuse can be a lifelong affliction (not necessarily consumption, but as a psychological trait). The intermittent uncertainty and chaos next of kin can be exposed to call for a good measure of enduring strength, which doesn’t come by itself.
The book charts ways of connecting.
Misbrug i psykologisk perspektiv — mødet med mennesket bag rusen (Abuse in Psychological Perspective — meeting the person behind the intoxication), a book in Danish on abuse, conceived and written by five professionals — Helle Kjær, Eric Allouche, Charlotte Silas Houlberg, Birgitte Thylstrup, and Helle Lindgaard — with the help of some of their users/patients/clients: Kenneth, Anna, Lasse, Rubin, Jan, Oliver, Line, Mads, Maria, and Camilla.