When I was in medical school, I was APALLED at drug use. I chastised my friends who smoked weed and would go into an almost state of panic if I saw anyone doing a line of coke in my presence. By the time I went into residency in New York City and started to see the most extreme forms of drug use, I was conditioned to address “junkies” like the rest of the medical system had taught me to; with judgment. One night when I was on call in the Emergency Department at Roosevelt Hospital (the hospital where John Lennon died) a young man walked in with an infection on his neck. He had stabbed himself with a heroin syringe aiming at his jugular vein a few days prior. A Latin man like me, a sinuous black and red tattoo on the side of his neck was made indecipherable by the soft tissue inflammation.

I let curiosity switch seats with judgment inside me for a second. I spent a significant time that night inside the emergency room box with him. After some time talking, I asked him; “What is it like, the heroin? Is it like going to heaven? How amazing are the sensations it gives you, that you would go through such lengths to get it?”. His answer lives with me to this day: “It’s the only thing that takes the pain away”. Through the rest of my career, I have never seen drug use the same way again, my role as a provider will always be to try and understand the pain and suffering behind the use of a substance, and allow compassion and understanding to lead the way, never judgement.

IFS believes that it is a part of us that has decided that relying on a substance is necessary at any given moment, and this part is always acting with a good intention at hand.

The following tends to be true for parts that carry on the role of substance use: ‍

• The more this part is convinced that keeping certain type of emotions, sensations, thoughts, or memories away from awareness, the harder it will work on making us use the substance. The substance using part has a good intention of staving off burdens that it believes we could not manage.
• There is usually a strong opposing critic working against the substance using part. This well-intended critic throws scathing remarks at the substance using part (e.g., “the next morning guilt”). The critic part wants the substance use to decrease or end, but sadly, it usually creates the opposite effect: in part because both parts then engage in an escalation of each of their roles, and in part also since strong criticism creates more shame or worthlessness, or other strong emotions that generally are the ones that put the substance using part into motion.
• If the substance using part has been working constantly for a long time, it has taken over a significant portion of the volition and reward systems of the brain (it has made its home in our neurobiology, mainly dopamine responsive areas of the brain), and it may seem like its role is almost automatic. This can bring about other parts that feel rather hopeless that anything will ever change.

Tending to this entire system that suffers and taking the time to get to know all the parts: the substance using one, the critic, the hopeless ones, and the little frail ones carrying the burdens of worthlessness, humiliation, shame or other strong emotions, will lead to a significant decompression of this system. A system that suffers less, will naturally activate its substance seeking parts less: this is the work of IFS. Furthermore, systems that have been operating with strong substance use for long, might need the help of some psychopharmaceutical intervention as a “stepping down” transitory intervention (here a prescribing provider will be useful) and -if not already present- aiming at building a stronger self-care routine (particularly with physical exercise if possible) in order to offer these parts a new source of dopamine as the former source is decreased.  

Not all drugs are the same. Crystal meth is not the same as marihuana. Heroin is not the same as tobacco. Alcohol is not the same as ketamine. The dialogue amongst our parts revolving each of these particular substances touches on a particular set of needs our system has decided to fulfill more or less successfully from the particular substance at hand due to its singular psychotropic properties. Your system might have needed the sedation of Xanax, or to silence a scathing internal critic with alcohol, or to become free from oppressive numbing through cannabis or amphetamines (Adderall, Ritalin, cocaine). The conversation -and therefore the healing- falls short by just focusing on restriction or abolition, without understanding the why’s with openheartedness and compassion.

I tend to think about substances (psychotropic drugs) as a dialogue between virtue and burden. For example, alcohol use can be somewhat virtuous when a mindful glass of wine is shared at dinner to create a sense of community, relaxing our central nervous systems in unison with moderation to become more playful, less rigid and more open. However, the same alcohol can be a glass of vodka in the morning before work to stave off feelings of worthlessness and panic; or drinking until passing out since the escalation of critic and other parts in the system is of such magnitude unconsciousness is the only plausible ending to the evening. On that same line -used with moderation- it is easy to think about the virtue of substances like psylocibin (mushrooms) or cannabis (marihuana). On the other hand, as a healthcare provider it is hard for me to believe drugs like Crystal Meth or Cocaine carry enough virtue to justify their burden -just from a biomedical risk perspective. But how much the balance skews in one direction or the other will have to do with the place from which our system is using the substance. Compulsory use, the use wherein no internal dialogue is happening and the behavior is automatic, is likely stemming from a deeply burdened part within us, a significant source of suffering, and a wonderful invitation to heal.

It is no coincidence that despite the advances in psychopharmacology, medicine still cannot obtain better results in addiction treatment than a 12-step program. The reason for this -I believe- is our need for connection. Primarily, addiction is a problem of connection: internal disconnection (ignored parts) and external disconnection (loneliness, an epidemic of our time). 12-step programs foster a sense of community with others suffering from dependency as well. This is not a “little garnish piece” on the treatment plan: connecting with others might just be one of the most powerful elements in healing. Our systems yearn to be witnessed in their wholeness, by us and by others who care about us.

‍