In this extended essay, experts address both the recovery and the long-term goal of healing from addiction, arguing that a full cure from drug addiction or habitual addiction can be achieved. Combining both the principles of systemic therapy and experience gained through years of counseling, they have developed a unique model called “in-depth systemic” therapy, which extends the classic model by introducing and expanding on the mental dimension. The central point of this work is the thesis that addicts themselves have to reorganize and restructure their own habitual ways of perception and cognition, with Vipassana meditation serving as the instrument to realize this transformation. Vipassana comprises an ethical lifestyle, concentration of the mind through meditation, and working progressively on one’s one mental-somatic models, offering a unique and successful approach to the treatment of addiction.
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About the Author
Leo Gürtler is a psychologist with a PhD in educational sciences and a systemic coach and therapist. Urban M. Studer is a mathematical physicist, a therapeutic researcher, and the leader of internal case management at the Swiss Federal Railway. Gerhard Scholz is a sociologist and founder and CEO at Start Again. Kent C. Berridge is a professor of psychology and neuroscience at the University of Michigan.
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AWARENESS and WISDOM in Addiction Therapy
The In-depth Systemics Treatment of Mental-somatic Models
By Leo Gürtler, Urban M. Studer, Gerhard Scholz, Judy Caughley, Luke Matthews, Ernst Arnold
Pariyatti PublishingCopyright © 2011 Leo Gürtler, Urban M. Studer, & Gerhard Scholz | Karlsruhe, Germany; Winterthur, Switzerland
All rights reserved.
On the concept of the In-depth Systemics approach
The In-depth Systemics approach is a specific form of continuous effort to help others process dysfunctional mental-somatic models (patterns of thinking, feeling, and doing). It is based on the ancient wisdom that (self-) deceptions will be dissolved if they are countered by direct experience rooted in systematic self-observation by applying the techniques of mindfulness and wisdom meditation. This wisdom refers to the realizations of the historical Buddha, Siddhattha Gotama, who lived in India more than 2500 years ago.
In this essay we present the In-depth Systemics approach and its practical implementation through the example of in-depth work with addiction. In-depth Systemics is, however, effective not only for addictions. It can be applied in a multiplicity of professional contexts (e.g., diverse occupations in health services, case management, training and coaching high-level employees, learning communities, athletics, etc.). Employing the approach in these other areas is not a matter of simple transfer, but requires applying certain principles systematically, working with one's own mental-somatic models and adapting these to the specific context in each case. To keep this essay short and simple we present the application of the In-depth Systemics approach in the area of drug addiction only. The text intends, however, to open up a vision beyond drug addiction, a vision that was formed during our many years of practical institutional experience and scientific evaluation. We hope this vision will reach, equally, meditators in their efforts to develop a more professional approach to their work, and professionals in their efforts toward integration of their own meditation experience.CHAPTER 2
Addiction is one of the most impressive variants of the loss of functional autonomy in the life of the individual. Rarely are the social descent, the continual injuries to the body, the inability to utilize the potential for autonomy, etc., so obvious. When treating an addiction, one constantly faces the challenge of arranging appropriate basic conditions that will actually permit addicted persons to have experiences that lead them to disentangle themselves gradually from the addiction, and at the same time let them recognize that a purely intellectual insight into their addiction is not sufficient for engaging mentally at a deeper level. This essay describes a combined approach in which the meditation teachings of the Buddha are integrated with sociological as well as psychological perspectives and neurobiological understanding. The key ingredient,Vipassana meditation, is highlighted as the essential instrument for engaging the deeper layers of addiction. This modus operandi originated at the Swiss addiction therapy center start again, which has successfully applied In-depth Systemics treatment since 1992. There the concept is based on the combined use of skillfully interwoven case-specific addiction therapy, systemic couples and family therapy, self-help, and the meditation techniques of Anapana-sati and Vipassana.
Understanding the In-depth Systemics concept requires a basic introduction to the typical aspects of the logic of addiction as a form of impaired autonomy (see section 6.2 for more details on the concept of autonomy). From this we can discern the consequences for therapeutic practice. First we present relevant models for explaining addiction. Then the practical perspective of Vipassana is underlined, followed by a short outline of the factors necessary for successful recovery from addiction. The integrated concept of start again, namely the In-depth Systemics approach, is described next. An extensive case study of the effectiveness of the therapeutic program is available (Studer, 1998) from which we quote the most important results. We then formulate hypotheses about the principles of recovery using, as examples, certain cases from a catamnesis investigation that one author (Gürtler) carried out (Gürtler, Studer, and Scholz, 2010). Finally, some fundamental considerations are given to the place of relapse and compliance in addiction therapy.CHAPTER 3
Foundations — about the logic of addiction
In practical work with persons showing addicted behavior, many characteristics marking the logic of addiction, some of which we shall examine below, stand out strikingly. In our opinion it is necessary to understand these characteristics in order to create a realistic starting point for recovery and/or disentanglement from addiction. This base allows us to take a stable therapeutic position when facing the severely impaired personal autonomy found with addiction. Such a professional therapeutic attitude manifests in the ability to maintain a stable mind, reacting neither with euphoria nor with pessimism to clients' actions and to events, and to stay in close contact with them. It permits the therapist to work with them, engaging directly with the well-known impairments, and to attempt to enhance the remaining autonomy potential and gradually extend it. Drawing from a pool of so many characteristics, we concentrate on (1) the contradictory unit of "the need to decide and the obligation to justify," (2) the falling apart of subjective reasons and objectively restorable motives, and (3) the large gaps among thinking, feeling, and doing.
3.1 The contradictory unit of "the need to decide and the obligation to justify"
Antoine de Saint-Exupéry (1900–1944) has an impressive description of the meeting of the little prince with the tippler in Chapter 12 of his famous book The Little Prince:
"What are you doing there?" he said to the tippler. ... "I'm drinking," replied the tippler. "Why are you drinking?" asked the little prince. "To forget," replied the tippler. "To forget what?" inquired the little prince, already feeling sorry for him. "To forget that I'm ashamed," the tippler confessed, hanging his head. "Ashamed of what?" insisted the little prince, wanting to help him. "Ashamed of drinking!" concluded the tippler, who then completely locked himself up in silence. And the little prince went away, puzzled.
Two important points are addressed here that determine therapeutic work: past actions (consumption) justify current actions (consumption) justify future actions (consumption). Addicted behavior is characterized by contiguous units of convoluted, contradictory decisions and justifications, and this mode may easily spread to those in contact with addicted persons, such as family members or therapists. There is a constant necessity to make, act on, and justify (at least latently) all decisions (Oevermann, 1997; Hildenbrand, 1995). This process is always embedded in a particular social framework, such that the subjectively experienced freedom to act often encounters objective obstacles that may quickly limit the, at first, infinite potential for freedom (Rogers, quoted in Revenstorf, 1993). Humans move between self-control and loss of control, and must learn to integrate this contradictory unit appropriately, molding it skillfully into daily life. Addicted persons have a distorted experience of this situation; therefore, they often misjudge their actual scope of action and existing autonomy. Where loss of control prevails — for instance with their evident dependency problem, which they cannot shed by means of conscious control — they presume autonomy, but when the possibility of self-determination presents itself (e.g., in arranging one's daily life) they do not take advantage of it but allow their stake in autonomy to diminish. The justifications the tippler gives to the little prince seem congruent to this reasoning: "Being ashamed" is based on "Because I drink!" and vice versa. Both arguments belong to spheres that are not easily controlled. Initially, change is not within sight because any attempt at solving a problem, already seen as an escape, is prevented by further escape (into drugs). In the short term a condition of relaxation or happiness is felt, but in the long term one's potential for independence diminishes more and more. This analysis demonstrates the short but practical definition of addiction made by David Foster Wallace (1998) (Interestingly, this definition comes from a man who was an author and professor of literature, not someone from the social sciences):
"Something is malignantly addictive if (1) it causes real problems for the addict, and (2) it offers itself as a relief from the very problems it causes."
From a practical point of view, this means we need to look again and again, together with the addicted person, at what is real and what is not real. This process of learning to separate reality from illusion and delusion is concretely realized in the steps toward autonomy actually undertaken by addicted persons. Thus, strictly speaking, work on the addiction begins when it is finally about changing past habits and standing on one's own two feet. Then is the time to demonstrate whether previous therapeutic work was successful. Success occurs if, in fact, clients undertake steps based in reality (e.g., applying for a job or training, etc.) — even if at first they fail. Failure is not that important; what is, is continuous effort. It is here that differences between self-reporting based on illusory autonomy and actually completed, "real" actions become apparent.
The second important aspect of the example of the little prince and the tippler is the effectiveness of social interaction. One notices that, confronted with the self-destructive behavior of the tippler, the little prince develops compassion, reacts with emotion, and would like to help. Such a naive reaction — a "wish to help" — is counterproductive with severely addicted persons, precisely because their first priority is to learn to do something according to their own impetus, i.e., to be intrinsically motivated, and to separate themselves from their dependence on other people in day-to-day life. At start again, in order to withdraw support for an attitude of nonactivity and nonengagement in the clients, the fewest possible opportunities for distraction are offered and a certain "boredom" is induced. We expect that they will then be compelled to engage with reality — by determining, for example, how to organize each day in a meaningful fashion. Multifarious possibilities for learning result when clients attempt autonomy and face the possibility of failure — a crucial and essential element in the concept of start again. It is assumed that, only if the possibility of failure actually exists in an action or a plan, a real crisis might develop, and with it a real chance for growth in successfully mastering it. To master a crisis — without falling back into the erroneous habit of consumption in the face of failure — is a major progress for addicted persons. Experiencing and mastering crises positively affects their practical life skills for the long term. Then we can speak about "structural transformation," because something new has been attempted.
The In-depth Systemics intervention model (detailed in section 6.1f.) comes into effect during direct interaction with clients. In fact, the therapists are also working on themselves — on their thinking patterns, on the interaction of mental craving and corporeal sensations, and on their own individual socio-biographic development. In systemic terms, "What is valid for clients, is likewise valid for therapists." Therefore, complementing their clients, the therapists must not withdraw like the little prince when facing refusal. This requires a constant process of self-reflection in order to recognize mutual transference and emotional reactions, and to deal with them with full awareness. Thus it becomes clear that all interventions initiated by therapists are filtered by the subjective constructions of clients. Of course, the same is true in reverse: all the actions of the clients are filtered by the subjective constructions of therapists. If such interventions are seen as rejections, taken personally, or not understood as manifestations of the structure of addicted behavior, then therapy is threatened with failure in the long term because a resilient therapeutic relationship does not develop.
The principle we need to apply is this: ways of behaving may be rejected but not persons. Here awareness, and wisdom built through awareness, enable therapists to observe their own emotional and mental-somatic processes with sufficient distance to avoid getting lost in them, suppressing them, or acting them out. With this attitude they can then engage with addicted behavior. This requires continuous work on their own mental models and autonomy, the development of compassion without getting ensnarled in sympathy, the realistic development of an optimism that is not easily shaken, and a methodically controlled contact with clients. This last, depending on the case, calls for the creation of appropriate contexts for reality checks. The underlying process of liberation from thinking patterns, as well as from mental-somatic models, is guided by the practice of Vipassana meditation. This will be explained in more detail in section 4.3.
3.1.1 Falling apart of subjective justifications and objectively restorable motives
There may be many reasons for an initial motivation for addiction therapy, and the desire for a completely abstinent life is not always preeminent. The following sentence from an application letter to start again stands "quasi-prototypically" for an abundance of motives at the beginning of addiction therapy:
"I want to get a grip on my addiction."
We worked out, on the basis of an analysis using the Objective Hermeneutics method (Oevermann et al., 1979; Oevermann, 2000), that this statement is not identical with the colloquial, "I wish to be free from addiction." This implies the intention never again to come in contact with addiction. In the former, a desire is expressed to control and contain the addiction. Thus it means not to be really free from addiction, because what one holds — what one keeps under control — cannot be released. Unconsciously, a continued but controlled consumption is intended. A past practice in one's life thereby conceptualizes the vision for a future practice. This is not something new; rather, it demonstrates an unconscious effort to maintain the (harmful) status quo. For the addict, the central question then becomes, "how can therapy help me learn to consume drugs safely, without negative physical, personal, and social consequences?" The unavoidable problems this will create in future addiction therapy are obvious. It will be necessary again and again, together with clients, to take up and reflect on their own perspectives, followed by interactions described in section 3.1. Therapists are asked to identify their counterpart's offers of interaction in the context of the case history and to respond appropriately. It becomes clear how much continuous work this means for therapists themselves, forced as they are to overcome their own mental somatic models and worldviews—a very difficult task!
3.2 The large gap among feeling, thinking, and doing
The phenomenon that feeling, thinking, and doing stand incongruently side by side can be observed, for example, when addicted persons reason very seriously about their motives for exiting from addiction or when they envision plans for the future — and yet the next moment, for whatever reasons, consumption is again in the foreground and there is clear risk of an incident. From both the viewpoint of neurobiology (Robinson & Berridge, 2003) and the wisdom of Theravada Buddhism, addicted actions are processes operating unconsciously. Acting (procurement and consumption) is initiated and steered from a deep level that is not accessible to most people. How the action is guided is also beyond awareness. At the time addicted persons experience the push of maximum desire for drugs (craving, or in their language, "the itch"), we observe that they are still able to give information about themselves and their internal processes of desire in a strangely dissociated, indifferent way. However, this observation needs to be evaluated independently of their ability to be aware of drug craving as such, to detach from it gradually, and to counter the insatiable thirst with something. Here we see that intellectual understanding has no effective influence on actual action. The major task of in-depth treatment of addiction must therefore be to impart to addicted persons experiences that enable them to make an analytical study of the phenomenon of their own addiction within their own mind-body system. Awareness and wisdom, or, as practiced at start again, Anapana-sati and Vipassana, are the tools of choice to experience addiction on the mental-somatic level and dissolve it gradually. The direct experience of one's own addiction on this level leads simultaneously to its slow dissolution. It means that one experiences directly what addiction actually is through intensive engagement with oneself in oneself. This experience leads to the development of a personal wisdom, i.e., how one has to work personally with one's own mental-somatic addiction complex in order to allow self-healing processes to occur.
Excerpted from AWARENESS and WISDOM in Addiction Therapy by Leo Gürtler, Urban M. Studer, Gerhard Scholz, Judy Caughley, Luke Matthews, Ernst Arnold. Copyright © 2011 Leo Gürtler, Urban M. Studer, & Gerhard Scholz | Karlsruhe, Germany; Winterthur, Switzerland. Excerpted by permission of Pariyatti Publishing.
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Table of Contents
List of Figures,
1 On the concept of the In-depth Systemics approach,
3 Foundations – about the logic of addiction,
4 Models to explain addiction,
5 Consequences – the goal of therapeutic actions,
6 Intervention and the In-depth Systemics approach,
8 Catamnestic findings,