Immediately after the first Accomplices’ Meeting in psychiatry and psychology, the second took place with psychiatrist Shird-Dieter Schindler and Corinna Obrist, a psychologist and psychotherapist who is Head of the women’s section at the Vienna Favoriten Prison, a special facility with a mandate to treat prisoners with addictions*.
TREATMENT AND DEALING WITH ADDICTION: A DEVELOPMENT
In retrospect, Shird Schindler identified four phases in how addiction is dealt with: in the 1980s the focus was on concepts leading to a cure, and in the 1990s, with substitution treatments, attention shifted to treatment concepts. He sees the 2000s as characterised by the sobering realization that neither of the previous approaches had provided a real solution. The current situation in the 2010s he described as back-tracking: one has now arrived at a more realistic assessment and addiction is viewed as a chronic illness.
In Schindler’s opinion, dealing with addiction as a chronic illness demands individualized treatment tailored to each phase of the illness: “I need an appropriate depth of intervention and choice of treatment for each phase of the chronic illness. To differentiate among these alternatives for treatment is the task we currently face.” The psychiatrist said that an advantage is that there is now a larger spectrum of recognized forms of therapy.
Corinna Obrist shares this view and recommends that this diversity be accepted and at the same time one’s expectations of treatment outcomes should be lowered, for these often reflect expectations of middle class society.
In Corinna Obrist’s view a gender-specific concept is an important aspect of this individualized treatment. However, currently the profile of the gender and queer thematic complexes is not anchored in the relevant institutions, such as universities and the institutions that train therapists. The assignment of gender roles also plays a role in the development of addiction and must therefore be taken into account in developing treatment concepts and models, particularly with respect to offers to quit.
SUBSTITUTION AS ALLEVIATION OF SUFFERING?
Understanding addiction as a chronic illness gives rise to complex social and subject-specific issues, including how to deal with substitution and the objectives of treatment and prevention.
Corinna Obrist raised the question of why, when addicts are given substitution or medication, is it necessary that these patients should want to bring about a change? Severely traumatized people should surely be accorded the right to amelioration of their pain through chemical substances under humane conditions without automatically presupposing a will to change. At the same time individualized offers to quit need to be formulated which are both high-threshold and low-threshold: “Can’t I even just sedate myself so that I no longer feel the pain without having to want something or having to act as though I want something, and in spite of everything can’t I live a dignified life?”
In this context Corinna Obrist is in favor of far-reaching de-criminalization, whereas Shird Schindler advocates reducing accepted legalized narcotics instead of legalizing “hard” drugs. Here his main concern is prevention: “Early recognition and treatment of suffering so that use of addictive substances is not needed.”
CONTROL, INNER FREEDOM AND ADDICTION
In spite of the diversity of forms taken by the syndrome of addiction, Shird Schindler’s long-term studies reveal significant similarities among patients in the course of treatment. Particularly striking is the finding that “even after eight months of psychotherapy in our clinic the self-alienation of the patients on the existence scale does not change significantly, that is, it remains relatively constant at a low level, which for us was ultimately a trait marker: of all the factors this was the only one that did not change or hardly at all.”
Self-alienation is an indicator of the extent of inner freedom: “How much freedom can I allow myself, how may I be? If I only give myself a minimum of freedom, then I soon get problems. Even in moments when I am tired, when I’m a bit apathetic, I exceed my own personal limits and I am dissatisfied with myself. The extent to which I give myself freedom is for me one of the main criteria of how strong the superego is. At this point I’ll get a rap on the knuckles because I don’t fulfill the expectations. For me this has a lot to do with addiction. What was surprising was that all other factors changed during the treatment — sometimes within the space of a couple of months — but the space of inner freedom was the only one that remained stationary and narrow.”
The study showed that transcendence also tends to be at a constantly low level among the patients. However, Schindler sees in its expansion — a detour via relativization of the self in confrontation with something larger — a possibility of enlarging inner freedom (e.g., religion or the twelve-step programs).
In this connection “control”, as the “biggest myth in the treatment of addiction” (C. Obrist), plays an important role. Whereas patients would have an alternative to control by means of transcendence, for example, in practice addicts as well as therapists and supportive caregivers believe that the problem of addiction can be solved by continuous control (self-monitoring, external control such as urine analysis, inspections and so on).
In this regard, Corinna Obrist is convinced that it is necessary to think about new models: “This is, after all, a paradigm in addiction treatment — that the addicts must monitor themselves and must also believe that their addiction is controllable. But addiction is not controllable. All we do is to control the addicts. And this is done in prison anyway; we continually carry out inspections, like taking urine samples and analyzing the inmates’ hair. Sometimes it seems to me that the addicts and the rest of humankind all have the same idea of control. But control also has something to do with “pulling yourself together” and “mastering intentionally” and this completely contradicts the notion that addiction is an illness.” A relapse, for example, is a symptom of the illness which needs to be reflected on as such — it must not be covered up nor should it be penalized. But on the other hand control is necessary in order to provide an environment that is drug-free and as safe as possible; this applies both to treatment centers and to prisons: “One is simply trying to provide a protected haven, but one must equally accept the fact that there will be relapses. Strangely enough, for a long time addiction treatment centers regarded relapses as highly problematic, although the relapse is a characteristic of the illness. People who don’t suffer from the illness of addiction, don’t have relapses. I have always found this rather paradoxical.” (Shird Schindler).
Both Corinna Obrist and Shird Schindler agreed that the fall of the (Austrian) abstinence paradigm was an important and positive change in the treatment of addicts; however, in Schindler’s opinion its implementation in practice is not yet optimal. There is not yet enough experience in dealing with relapses as symptoms but also as opportunities: “The anger and exasperation that there is when someone actually does have a relapse does not quite correspond with the new view.”
What remains is the disappointment of the person who has had a relapse, which has a very negative influence and keeps the downward spiral going, and this in turn triggers an abstinence violation syndrome.
*Vienna-Favoriten Prison “has a mandate to treat prisoners who have committed an offence in connection with the consumption of drugs or other intoxicating substances and have been sentenced to imprisonment by a criminal court (§ 22 Austrian Penal Code). In addition, prisoners in other penal institutions can apply for a transfer to this prison to be treated for addiction (§ 68a Penal Procedure Code).” For further information visit the prison’s official website (in German).
Transcription and Text: Nina Glockner
Translation: Gloria Custance & Isaac Custance