Addiction, trauma and the healing power of Chairwork.

Introduction: Clinicians who know Scott Kellogg—the clinician, professor, trainer and thought-leader in addiction theory and treatment—might be surprised to hear him, in session, exhorting his patients to forcefully declare their love of drugs and insisting that they exclaim how desperately they fear life without substances. Although he is flexible and patient-centered with respect to the goals of treatment—with abstinence or moderation both on the table—he is all-in when it comes to ensuring that treatment, if at all possible, becomes a powerful and transformational endeavor…Richard Juman

Patient: “I want the drugs. I love the drugs. I don’t want to stop. I love the way they make me feel and I’m not ready to give them up. They help me. They help me better than anything. I feel bad, you know. I feel bad and they help me get through. I want them and I’m not ready to give them up.”

Therapist: “I want them, I love them, and I’m not prepared to give them up.”

Patient: “I want them, I love them, and I will not stop. It scares me to even think about it.”

Therapist: “Now switch and go to that chair. Speak from the part that wants something different.” (Patient switches chairs.)

Patient: “I am really unhappy. I’m ruining my life. I’m wasting it. I worked so hard to get the things I wanted. I wanted a career and I’m losing everything. This is not what I wanted. I hate this life.”

Therapist: “I hate this life and I want a better one.”

Patient: “Yes, I hate this life and I want a better one. I want the life I wanted.”

Therapist: “Again.”

Patient: “I want a better life. I want the life I wanted. I had plans. The drugs and alcohol are destroying everything. They are ruining it. I want my real life back.”

Therapist: “Say this slowly: You say the drugs are helping, but they’re not. I want my life back now.”

Patient: “You say the drugs are helping but they’re not. They’re killing me. I want my life back and I want it back now!”

While this is a fictional example, this is the kind of motivational dialogue that I invite my patients to engage in.

In 2001, after years as a practicing psychologist, I discovered Chairwork, and it has been a central part of my psychotherapy practice ever since. Originally developed by Dr. Jacob Moreno, the founder of Psychodrama, it was further developed and made famous in the 1960s by Dr. Fritz Perls, the creator of Gestalt Therapy. At the center of the practice is a belief that there is a healing and transformative power in: (1) giving voice to one’s inner parts, modes, and selves; and (2) enacting or re-enacting scenes from the past, present, or future.

Chairwork is an extraordinarily powerful and flexible way of engaging with both the internal and external challenges and the suffering that my patients are wrestling with. As a therapist, I want to use interventions that are powerful enough to transform my patients’ lives, and I have found nothing more powerful than Chairwork. As Zerka Moreno wrote in The World of Multiple Stages, “Though often dealing with traumas of the past, it is also concerned with problems in the present and expectations of the future, as rehearsals for living, helping to make alterations as indicated. Role playing can be done as animals, spirits, delusions or hallucinations, voices, body parts, ideas, visions, the departed….” (p. ix). When doing addiction psychotherapy, I have found that it can be especially useful when I am seeking to clarify motivation and heal and resolve trauma.

In terms of motivation, I begin by sitting down with a patient and going through a Decisional Balance exercise with them. First, I ask them to tell me about the positives and negatives of their drug use. Then, I ask them to identify what they know or imagine would be the positives of making some kind of change—whether it is harm reduction, moderation, or abstinence—and what they know or imagine might be the downside of making these changes. I like to do this first because it allows us to explore the different parameters of the substance use while also “warming up” and anchoring the patient for what will come next.

I then set up two chairs, which in this case, are situated a few feet apart, facing each other. I have one chair represent the forces inside the patient that want to continue to use drugs, which includes both the part that finds the drugs to be helpful and meaningful, and the part that fears the prospect of changing. In the opposite chair, I invite them to embody the forces of change, which would include both the parts that are pained by the addictive behavior and those that want something better. As we do this, two themes usually emerge from the “drug use chair.” The first is centered on the hedonic or pleasurable aspects of the substances and the second is that of self-medication. Since I want them to speak from each perspective as clearly and forcefully as possible, I work with them to say things like: “I really love the drugs. They just work for me. I can’t imagine life without them. I want to keep using them. They help me function. I feel bad a lot of the time and they get me through the hard times. I don’t know what I’d do without them. I want them and I will not give them up.”

In the other chair, I want them to speak from the part, or parts, that want some kind of change. Here, the themes of fear and possibility frequently appear. Again, wanting them to speak with a strong and focused voice, I encourage them to say things like: “You say that you love the drugs, but they are killing us. I’m really afraid. My life is falling apart. Something bad is going to happen if I don’t stop or do something. I can feel it. This is my life and I do not want to spend it addicted to drugs. I wasn’t put on this earth to be an alcoholic. I am wasting my life and I want to use it for something better. I want something better!” They would then return to the first chair and reiterate the desire to use, and then come back to this one where the voice for change gets to speak again. I will ask them to go back and forth repeatedly until I sense that some kind of resolution has begun to take place.

You may have noticed the recurrent use of the words “I” and “want.” In the early dialogues, it is important for patients to claim ontological ownership, which means that they “own” their use of substances and they “own” their desire for something difference. Following Perls’ example, I want them to use existential language, which means they use phrases like “I want,” “I am choosing,” “I am deciding,” and “I will.” A central goal is for the desire to use substances to encounter and dialogue with the desire to change. It has been my experience that patients consistently find this to be a powerful experience. To speak this openly and clearly about their desire to use substances can be a bit shocking to them, but it also extremely helpful for them to articulate a part of their inner self that they most likely have never spoken aloud.

At the end, I invite them to stand in the middle between the two chairs so that they can get a sense of the balance between the parts that want to keep using and the parts that want to make changes. Are they 50-50, 60-40, 90-10?  After that, we can sit down and begin to sort out a plan of action that addresses the needs and concerns of both sides. This will most likely involve addressing the substance use, taking steps to diminish the underlying pain and psychopathology, and exploring ways to actualize the part that wants a better future. Read more “the fix”…