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In working with our patients at CeDAR, we often look at the interplay between thoughts, emotions, and behaviors. Because addictive disorders are ultimately about behaviors, we seek to build insight regarding the choices people make and the thought processing that occurs prior to drinking, using drugs, etc.
Our patients are all experiencing a severe amount of stress in their respective lives, and this stress has the potential to build up to overwhelming levels. What happens when someone experiences this stress and anxiety? It can be very useful for patients to build awareness around how they cope with anxiety, with an emphasis on coping in a mature and healthy way. Very often, people are struggling with limited awareness. We can use our observations at CeDAR to give people feedback ‘real-time’ about ways in which we witness them coping.
Sometimes behaviors are driven entirely by emotions with little rhyme or reason. We provide patients with some psychological education around the hierarchy of defense mechanisms, as they often find this fascinating and a useful tool on which to build insight. One of the more common, and destructive defenses we see is called “Acting-Out.” To discuss this specific defense in greater detail, we need to set the framework for the 4-part defense hierarchy as originally described by Anna Freud (Sigmund’s daughter) and in a modern fashion, psychiatrist George Vaillant (who also heavily studied alcoholism).
Mature defenses involve an awareness of the anxiety at hand as well as the coping skill used. A person in this territory tends to be reasonably grounded and volitional in life. Our goal through CeDAR is to help people live with a mature set of coping skills. These defense mechanisms include:
Neurotic defenses involve an awareness of the anxiety source, but not necessarily the coping mechanism used by the mind. All healthy people will live through both mature and neurotic defenses at different points in time. These include:
Immature defenses are employed by more stressed or struggling individuals. Someone in this position may be less aware of the anxiety source and also less aware of the behaviors. These include:
Primitive defense mechanisms are often a marker of severe impairment. They include significant distortions in reality and a poor sense of both the anxiety and the response to the anxiety. Examples include:
To summarize, higher levels defenses involve awareness of the source of the anxiety and the coping skill used to help. Lower level defenses involve a lack of awareness around both the source and the skill.
As we are working to help people heal in recovery, this always involves an appraisal of a person’s ‘battles.’ To drink or not to drink? To work or to play? To be patient or to throw a tantrum…
Acting-out involves the person unconsciously choosing the side of this battle which is often easier, more based on pleasure, and more based on a set of core drives. If someone is behaving in a way akin to “I want what I want when I want it!” they are likely acting-out.
This theme is regularly discussed in peer support programs such as Alcoholic’s Anonymous (AA) or Sexaholic’s Anonymous (SA). Many sponsors will use this language when working with someone, asking them if they had experienced cravings or urges to act-out. By working a program, someone is declaring that they are interested in changing and seeking something more long-term rather than the immediacy that the acting-out provides.
Luckily, things get easier over time. When people are further away from addictive patterns, their brains are often more calm and settled down. They are able to weigh the pros and the cons more effectively and make choices with an appreciation for their values. This leads to further strength and morale in that the person is starting to recover, feel positive about the change, and more optimistic moving forward.
If someone repeatedly is acting-out during their treatment course, we will constantly push them to start ‘acting-in.’ Acting-in isn’t a form of acting at all – it’s about talking! A treatment program such as CeDAR provides numerous spaces for someone to process their urges, share their anxieties and build insight. This is the whole point behind individual and group therapy. Sadly, many people fail to take advantage of these services.
What gets in the way of someone acting in? Maybe they are worried that they would be judged or stigmatized for their thoughts or feelings. Some people find the process of sharing and talking too exhausting. They may struggle with trust. They may be highly ambivalent about changing their lives. Ultimately, the therapeutic process works, but we need to encourage people to actively engage in the process.
Connecting this to our above hierarchy of defense mechanisms, we do hold a core assumption that greater awareness leads to greater flexibility, peace, and choice. These values are also present in dedicated 12-step programs, helping others to reflect more deeply about their addiction, relationships, etc. Through insight, people are able to live the lives they want and experience a sense of freedom. They no longer are slaves to addiction or internal forces outside of their field of view. They are able to develop a life worth living, the pure definition of Recovery.