It is always a bit shocking to realize how many patients with addiction have been traumatized. I made my usual rounds this morning and there were several patients who had suffered severe trauma as kids and the trauma is now coming out as rage, anxiety, depression and addictive behaviors.
One of the things that a colleague of mine pointed out about individuals with addiction is that addicts are among the only people who can comfortably hold two conflicting ideas in their head at the same time without suffering dissonance. One of my patients this morning talked about his absolute certainty that he is an alcoholic and is unable to drink, and in the next sentence toyed with the idea that having a few shots of vodka at night was not really such a bad thing for him. Clearly, the logic is absent, but the absence of logic is not evident to the patient. This ability to say two contradictory things without a problem makes family members and therapists puzzled at best and feeling helpless at worst.
Trauma and addiction allows people to create a psychic architecture that requires a lot of walls, closets, compartments and closed doors. It is okay to keep one thought in the living room, another thought in the bedroom, memories in the locked closet, anorexia in the kitchen, bulimia in the bathroom, gambling in the basement, and none of the thoughts or compulsions talk to or see each other. It even puzzles the owner of the house as to where things are and how to communicate at the right time. Generally, the thoughts leading to the dysfunctional behavior are quite stealthy and generally speak without being asked.
As the therapist, one is not able to just go around peeking into doors or emptying drawers on the floor. We can, however, give the owner permission to consider opening a shade and letting some additional light in. We can explore where the keys to the locks are kept, and try to get the thoughts in one room to talk to the thoughts in the other, or to help the owner consider remodeling the downstairs a bit to remove a door or a panel. I think of cognitive therapy as hanging mirrors around the house so that the reflections shed new light on the old perspectives.
It is illegal to remodel without a building permit, and sometimes the permission to change the structure is too expensive for the owner. It is comfortable to look at the cracks in the ceiling or the dingy walls. Sometimes it takes a flood or other natural disaster to force the remodeling after major structural damage has occurred.
Light and space are the enemies of the old thoughts and patterns. If done carefully, however, the owner may not have to suffer buyer’s remorse, and the end game may result in fewer rooms and more conversation.