Aiming higher

For most of my working life I believed that the services I worked in were simply not offering enough. Better care plans, more strategies, motivational interviewing, more cognitive tools – if we could only refine what we already had, the numbers would move.

I worked as a registered nurse in addiction services in the Netherlands and the UK, across prevention, treatment, aftercare and dual diagnosis, and in all those years I watched deeply motivated clients who wanted to stop continue to use. It wasn’t only what I saw myself. JAMA documented in 2000 that between 40 and 60 per cent of people relapse after treatment, and two and a half decades of refinement have not noticeably moved that number.

I came to realise that something essential was missing, and I no longer believe the problem is effort or execution. I believe it’s the level at which we aim. Our focus on changing behaviour might be too narrow, and might itself be producing the outcomes we keep getting. We need to go deeper – the identity layer I could not, and did not, reach.

It’s increasingly accepted that a dependency begins as a coping mechanism. Often it was the only one available to a nervous system carrying more than it could process at the time. And it worked, or it would never have taken hold.

A mask is a useful metaphor. It was put on because it worked – and it stayed on long enough to become the face a person could see from the inside. At that point the addiction is no longer something a person does, it’s something they take themselves to be. And a person who takes themselves to be a problem cannot be talked out of it at the level of behaviour, because every relapse confirms the identity, and every fight against the dependency is a fight against themselves. That conflict leads to shame, and shame invites relapse.

There is research pointing in this direction. Best and colleagues’ Social identity model of recovery describes recovery as an identity shift – new groups, new belonging, an ‘addict’ identity giving way to a recovery identity – and treats that shift as a mechanism of recovery rather than a by-product of it. What I’m describing goes one step further – not building a new identity to replace the old one, but recognising what was underneath the mask before it was worn.

The practice level of this is better mapped than you would expect, with two randomised trials in JAMA Psychiatry pointing the same way. There’s also something the evidence doesn’t show. The 2021 Cochrane review of 40 randomised trials found mindfulness-based interventions might slightly reduce days of substance use, with uncertain effects on abstinence and craving – but to me this an argument for fidelity and depth, rather than dismissal. 

It’s about capacity building. A person learns to meet a craving as an observable event – to feel it as sensation, locate it in the body, and watch it rise and crest and pass, without obeying it and without fighting it. One proposed mechanism is ‘de-centring’ – experiencing thoughts, sensations and cravings as events rather than as commands. And the capacity grows with repetition, the way any capacity does.

But here’s the interesting part – each time a craving is watched rather than fought, something quieter happens underneath. The person is, for a moment, no longer standing where the mask stands. They’re the one watching it. Nothing has been defeated, and nothing needed to be – the identity has simply loosened. To the coping mechanism itself, a person can finally say – you protected me once, and I have grown past needing you. In a body that has spent years at conflict with itself, that is a powerful shift.

So my proposal is, in addition to what works already – medication, trauma-informed care, counselling, peer support – add capacity building alongside every layer that holds people. If the literature is right, the difference doesn’t show in week one. It shows at month 12, in the people who are still standing – not by fighting harder, but by finding, underneath the mask, someone who was never craving anything.