Harm Reduction, Part Five: Exploring our Relationships with Substances

Hello to all, and thanks for your comments on my last four posts in this series.

Today, let's discuss one of my favorite topics: how our relationship with our substance of choice informs and impacts treatment.

​Just as we have intricately complex interactions with the people and institutions around us, we all have snowflake-style unique relationships to the substances that enter our bodies. One way to examine these unique connections is through the interaction of drug, set, and setting.

Drug, obviously, is the pharmacological action of the substance itself. This can include such considerations as: 

• how potent is it?
• how is it administered?
• how long does it last?
• how frequently is it used?
• how much is used?
• does it contain any adulterants, and what are they?
• what are the typical physical and psychological effects (depressant, stimulant, psychedelic, etc.)?

Though considerations of the substance's particular properties are necessary, they are not sufficient. There is a common tendency to reduce a drug's outcome strictly to its typical physical effects, and to see this as predictable and stable (for example, assuming alcohol will make you sociable and fun, or that cocaine inevitably leads to grandiose, manic behavior). The reality, as we shall see, is far more complex.

Set (or "mindset") refers to all possible variables that YOU as a substance user bring to the table, such as:

• personality style and traits
• overall mood patterns
• feelings while using
• mental health issues
• current stressors
• motivation and concentration 
• attitudes, expectations, and knowledge about the substance
• physical conditions and well-being
• your sociocultural background
• stage of change 
• personal and family history with the substance
• intentions for your experience
  

Setting is both the physical and social environment of the use:

• where you use (location, temperature, safety, lighting, noise, etc.)
• who you use with
• the general quality of your support system
• cultural sanction and beliefs around use, including legality
• prevailing social and spiritual views around what is real/unreal, how sanity/insanity are defined, and what is deemed acceptable to feel, think, and experience in your culture

The dynamic interaction between these three domains can produce an infinite variety of idiosyncratic responses, and it is vital for both users and treatment providers to consider all the variables involved.


From here, we can begin exploring the nuances of this interaction; a question that I commonly ask folks that I work with is: "If this was a person, what would your relationship be like?" 

Some possible answers might be:

• Coffee is an integral part of my morning routine, as well as my social group. I feel grateful for how it enhances my ability to work, and I miss it when it's not around. I have a loving relationship with coffee!
• Unlike people, alcohol has never let me down. It's reliable and dependable--always in the same place, at the same price, with the same effects. Why would I want to give up the one stable relationship in my life?
• I have a pretty ambivalent relationship with pot. It's pretty great at helping me sleep, which has always been a big concern for me. However, it's leaving me pretty foggy at work, and that's been getting me in trouble. I'm pretty torn about what to do about our relationship.
• I feel like I'm in an abusive marriage with meth--it always comes on sweet, reminding me of the good times we've had, but it eventually beats me up and leaves me by the roadside. I wish I could understand why I keep going back.

Substances can become so many things to us: lovers, friends, confidants, companions, tormentors. For those whose early lives have been lacking in attachments, they can provide a first experience of an ongoing, stable relationship. They can encourage us to freely express ourselves when we're inhibited, they can help us set boundaries with an intrusive environment, and they can give us a sense of power when we feel weak. They often offer to protect us from things we don't want to think and feel.

When we tell someone struggling with substance use that they should "just QUIT, already," ​we miss the opportunity to explore these complexities; we have also not yet provided them with any viable alternatives to getting their needs met. Any hope for enduring change must begin with unpacking the meanings behind this most intimate of partnerships, and exploring alternative ways of caring for oneself and coping with one's life.

Thanks so much for reading, and I hope this was interesting for you. Next time, I hope to delve into the heart of change/don't change ambivalence. Take care!