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For over 20 years, David Berenson has been a leading clinician and researcher into the dynamics of addiction and the interactions between addiction and family life. He was coauthor of the groundbreaking 1974 article in the journal Psychiatry titled "The Adaptive Consequences of Drinking," which helped to focus the attention of counselors and family therapists on problems of alcohol and other drug dependency. Since that time, through lectures, workshops, training seminars and publications, Berenson has continued to address and highlight the importance of these issues.
In the following interview, Berenson discusses these the integration of a spiritual perspective into family and addictions treatment. His seminal statement of the importance of this perspective (1990) will soon be republished in updated form as part of a larger collection.
OM: Attention to family issues is a standard part of addictions treatment today. But, that has not always been the case. Thirty years ago this was a new insight, and even today counselors and family practitioners see addictions in different ways. You completed a psychiatric residency in 1972, 25 years ago. How did you get interested in family dynamics and their relationship to addiction?
DB: I was fortunate that in my residency there was a very large family therapy component. In fact, that's why I selected it. Israel Zwerling was there, and he mentored Andy Ferber, who was my mentor. As a medical student I knew I wanted to be a psychiatrist, and I was exposed to family therapy. At that time Einstein [College of Medicine, Bronx State Hospital] had the best family therapy section in the country. Then, it came time to go into the Public Health Service. And, Peter Steinglass, who was a few years ahead of me in my residency and who was also interested in family therapy, was working at NIAAA. I'd had virtually no exposure in my residency to working with alcoholism or addictive problems. In fact, I did not consciously treat an alcoholic in my whole residency. Like many others, I just thought of them as unmotivated people who you sent to someone else.
I joined the NIAAA research project that involved seeing couples who lived on our unit for a week with an open bar. I was doing therapy, while Peter was doing interactional research. For at least part of the time, they would be drinking, so I got to see a little bit of the powerlessness and I also got intrigued by the whole area.
OM: Can you state briefly your own view of how family dynamics interact with addiction?
DB: Some people would say that the addiction is a result of family dynamics. And some people would say that the family has to work with someone who has a biological problem. But, a family systems point of view says that you don't worry about what's cause and effect. A lot of what happens is that family members get into automatic patternings; sometimes these are well-intentioned efforts to make the situation better, which may in fact make it worse, and sometimes they [family members] may have part of the action, which is now called "codependence." Steinglass described in his research what he called the "alcoholic family," in which, over multiple generations, alcohol is central to the functioning of the family. In other families, however, it may be only one generation but the marital pattern will tend to reinforce the drinking.
OM: So the drinking actually serves a function in the system?
DB: Yeah. That's what Steinglass, Davis, and I found [in 1974]. We got interested in aspects of the addictive cycle, an alternation between dry and wet. And what we saw was that family members went through the same oscillation as the drinker did. These were adaptive consequences. Perhaps there might be more expression of distorted intimate behaviors in the [period of] drinking, there might be more direct contact, more direct emotional interaction; sometimes the most contact might be when someone picks up the drinker to put him to bed.
OM: From your point of view, do you see it as essential that therapists understand the family field [environment] of the person coming for treatment, if they're going to understand the addiction at all?
DB: Parts of the family field ... what I've done is develop the idea of phasing. In each phase you need to understand different aspects of the family field. In Phase 1, you need to understand the interactions with significant others, you know, the classic enablers or codependents. Because--and this is probably my unique contribution to the field--what I've learned as an extension of Bowen's approach is that I will work with one or more people initially. If I have a choice of working only with the drinker or only with the significant other or spouse, I'd much prefer to work only with the significant other. That fits for me. It's really more an extension of AA/Al-Anon than it is of average family therapy practice in this country. Your average family therapist is going to be doing conjoint work. Whereas, if you take Bill Wilson's or Dr. Bob's recovery, their spouses "bottomed-out" before they did.
When I give workshops, I will often ask participants who have some degree of experience in the field, how many have seen a drinker or addict get sober without a prior shift on the part of the significant other. Very few. It's very rare that you get this "out of the blue" stuff. I try to use Twelve Step principles to get the significant other person to shift, or at least to get somewhat less reactive.
OM: Does this approach of working with the nondrinking "significant other" work?
DB: Yeah! It works tremendously well, and it saves amazing wear and tear. In alcoholic family systems, there is this over-responsible/under-responsible phenomenon. Bowen pointed out that it is much easier to tone down the functioning of an over-responsible person than to boost up an under-responsible one. The so-called "codependent" is frequently over-responsible. You can get through to that person much easier.
OM: You put together this idea of "phasing," which is similar to a developmental notion of recovery, for example, that 10 years sober isn't the same as 1 year.
DB: Yes, it totally corresponds to the phasing of individual recovery in the Twelve Steps.
OM: You use this notion of phasing in addictions treatment as a way to integrate disparate perspectives, the behavioral, disease model and family systems approaches. Can you talk about this a bit more?
DB: Really it just came to me. Initially, I knew there were at least two phases. Let's try to get people first dry [Phase 1], then let's see about getting them sober [Phase 2], which is a distinction A A makes. With couple work, let's see if we can get the drinking stopped and then let's see about getting intimacy. A lot of people come to this notion of phasing on their own; I'm not unique here. Steinglass, for example, says that after the drinking stops, there's the "emotional desert."
It's also, by the way, to save wear and tear on the therapist, and also a way to match skills to different clinical situations. There are different skills for different phases. You're not trying to do everything all at once. By working with different people on different focuses at different times, you don't get so overwhelmed. The trouble people have working with addictive problems is that it seems so chaotic, they can feel overwhelmed.
OM: Do you also find that it gets you out of this trap, namely that, if you don't deal with the family issues, they'll relapse, but if you do the family issues too soon, they'll relapse anyway? In other words, phasing gives you a way to pace the treatment.
DB: Yeah, exactly. That's a very good way to say it.
OM: You speak about Phase 3 work as the new frontier of family treatment. Can you say a little more about that?
DB: You see, Twelve Step programs are wonderful but they have the no cross-talk rule. [It is customary at many Twelve Step meetings for individuals to speak sequentially without discussion or questioning from other members.] Which is great, but there's a certain intimacy that requires cross-talk; it's called dialogue. So, let's say that people are participating in AA or Al-Anon, there's a certain intimacy in the meetings, which may not carry over into the relationship. And also, the Twelve Steps thing about don't carry resentments is a valuable suggestion, but also that comes out as don't clear out your anger. In most relationships, however, anger comes up and there has to be a way of responding to it without being too explosive. Also issues around intimacy and sex: I find that sponsors have such wisdom when it comes to what to do around drinking issues, but it's amazing how much lack of wisdom they can have around sex.
Phase 3 requires a different set of skills from the other two. What I say is: The alcohol counselor's--and I'm not sure how much longer we're going to have addictions counselors--set of skills is more appropriate than your average family therapy skills in Phase 1. Family therapy skills (Bowenian family-of-origin work; inner child work; structural family therapy) are more appropriate in Phase 2. Couple therapy skills, intimacy and relationships, are more appropriate in Phase 3.
Reflection Exercise #2
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