There is nothing curious about a drug addict's attachment to their drugs. Addiction is a powerful problem that in order to be successfully dealt with requires commitment and treatment. On the other hand, patients in treatment who are stably benefiting from MAT- medication assisted treatment, are attached to their Suboxone in a manner that is qualitatively different from the addictive hold that drugs have on a person in the sways of addiction.
We discovered this in our clinic when we changed from inviting stable patients to consider tapering off of their medication to simply asking them to taper their medication to a lowest effective dose. While it was expected that patients would be resistant and fearful of tapering off their medication, it was surprising to discover that they were equally resistant to even budge the dose when they were reminded that in tapering to a lowest effective dose there would be no loss of efficacy or support from the medicine. We would remind patients that making such a taper was logically no different than taking ones car into the shop to get a tune up for the purpose of getting the car to run efficiently and achieve its maximum miles per gallon.
Further, they were reminded that there were many upsides and no downsides to finding the lowest effective dose, amongst them:
-Lowering the dose would likely activate their natural internal opiate system so that their physical self could become a greater participant in their sense of wellbeing.
-Attempting the procedure would be an exercise that would help patients get a better psychological relationship to their medicine. In short, medications are a tool which patients should own, rather than feeling owned by them.
-Finally, it is pointed out to them that developing a proper psychological relationship to Suboxone is a part of preparing to graduate from counseling. Owning the medicine rather than being owned by it contributes to he psychological resilience that provides a layer of protection against relapse. When we graduate patients we want them to be in a place where they reward themselves fairly for their achievements in life rather than giving too much credit to their medicine.
So what is behind this irrational attachment to Suboxone, an attachment that is different from simply being addicted, an attachment that allows little flexibility in how the medicine is used?
One dimension I looked at is in the realm of self psychology. It seemed as if patients are attached to Suboxone as if it is a part of their physical self. Returning to the analogy of a car, taking ones car to the garage for a tune-up poses no more of an emotional threat than clipping ones fingernails. Yet in contemplating a taper, patients seem to anticipate that it will be like getting stitches; fingers are very much a part of the self, fingernails, hardly so.
Conceptualizing my patients resistance to a taper in terms of self psychology was helpful, but a deeper insight was afforded when I looked at the problem in terms of the residual impact of trauma. To this I give credit to one of our therapists who reminded me of the prevalence of trauma. He is a man with decades of experience not only treating patients, but in early times being a part of their world.
What's useful in taking a broad psychological perspective on our patients is that helping a patient 'rehab' is actually a matter of redressing all significant areas of their functioning that are impaired. It is important to not only help patients feel better, but we must have enough understanding of their circumstances to lead them along a path to being better.
Redressing issues is not always comfortable, but at the same time, need not be traumatic. It is here that the role of the therapist is most important as a guide. By not being afraid of discomfort yet protecting the patient from being overwhelmed a therapist can lead his patients along productive paths that, while challenging, are ultimately constructive. Challenge leads to self awareness which in turn leads to the capacity to take on even greater challenges.
So returning to the topic of trauma and its relationship to substance abusers, patients with unresolved trauma can be psychologically inflexible. It is as if they continue to live in a traumatic world rather than feeling welcome in the ordinary world where flexibility is an essential part of good living. In taking on the challenge to go through a brief and simple protocol to find their lowest effective dose, patients will be wrestling with the past and gaining freedom in the present. The process is not easy but is very constructive. The therapist who encourages them is actualizing behavior that will facilitate them developing a healthier emotional relationship to their medicine while at the same time helping them loosen unhealthy bonds from their past.