Substance Use and Abuse: Gay Lives in the Epidemic

We have spent two or three decades now with a medical model – a disease model – of substance abuse in, if you will pardon the expression, the driver’s seat.  But the idea of substance abuse as a disease is a descriptive model, a sometimes useful conceptualization, and is no more the reality than any model is the reality.  As Wittgenstein, the Austrian philosopher, said, “Language is not the world,” meaning, what we say about the world is not the world itself.

Acknowledging the sometimes utility of a disease model of substance abuse, there are other useful ways of talking about it, and I would like to propose one way today.  The disease model accomplishes some important things: it detaches moral stigma from substance abuse, and it has given rise to some effective interventions that can curb the actual abuse itself.   What it has not done, by in large – what it has often obstructed – is a clarification of whypeople use substances.  Disease in the traditional medical sense does not need reasons, it simply exists.  We do not – hopefully – speak of the purposes of a virus in the sense of human purposes.  But substance abuse is not a biological or microbiological process, it is something that people do.  And because that is the case, I would like to talk about why people might do that, what their purposes might be in doing that, what the human meanings of substance abuse might be.  And I will talk, of course, mostly about gay men in these regards.

As a psychologist, I am uncomfortable with the extent to which disease models remove the human meaning from substance abuse.  When people do things – particularly big, impairing, destructive things like “careers” in substance abuse – I am inclined to want to understand if there might be some meaning in the behavior.  For me, a disease model of substance abuse expresses a scientific reductionism that is increasingly common in our explanation of things.  In its purest form, scientific reductionism tells us that human life – our subjective experience of being alive – is really simply a collection of biochemical events – or, as a Star Trek alien told Captain Picard, “You are mostly ugly bags of water.”   But this is like saying that a cake is really nothing more than sugar, water, and flour.   True, in one model for describing things, but not the meaning we find when we eat cake – and for that matter, when we have feelings about another person or feel another human body.   Such reductionism, especially when it offers itself as the truth leaves out the matter of meaning.

Reductionism, in many forms, is becoming increasingly popular and is driven, in part, by our scientific enthusiasm for changing things – as well as by our desire to detach moral stigma from things we do.     Like the disease model of substance abuse, the pursuit of genetic or prenatal explanations for homosexuality is partially aimed at removing the moral stigma from it – not only for the homosexual him or herself, but for the parents who have been “blamed” for or felt guilt about hatching and raising a queer child.  But does not the need to detach moral stigma from homosexuality by providing explanations that are out of our control imply that if it were something we simply chose to be or do – if it were within our control – we would be guilty of the sin?   The political position that it’s O.K. to be gay, because “It is not a choice,” seems to me a significant human – and political – compromise.  Why not be gay on a whim?  Why should our society not protect the rights of “voluntary” gays the way it protects the rights of converted Jews?  And what becomes of the meaning of being gay if it is acceptable only in the way that Lou Gerhig’s Disease is “acceptable.”

So, the disease model of substance abuse eclipses the question of human meaning in substance abuse.  But what is the important meaning in drinking yourself into a drooling stupor seven nights a week?  The answer that I propose for our discussion today is that we use substances – moderately or otherwise – to alter our states of consciousness, and that we do that because our unaltered states of consciousness are too painful.  (That the altered states of consciousness can finally become too painful is a separate issue.)   To risk a reductionism of my own, human life is an event of the cerebral cortex, and we are probably unique in the animal kingdom in having a cortex that routinely makes itself miserable quite independently of physically induced misery.  We have, since the beginning of history, sought ways to alter our cortical experience, and true to the species, we have not only been imaginative, we have often been excessive and destructive.

Substance abuse conceived of as a disease – thus warranting “dual diagnosis” or primary diagnosis – invites us to ignore the psychological pain that so often – I will risk saying always – underlies the abuse.  There is no question that the abuse itself can become a major problem, that it can create its own destructive consequences, and that it can obstruct – indeed, become the medium for – avoiding the underlying issues.  But avoiding the underlying issues – the painful state of consciousness – is the point of the abuse from the very beginning.  With the exception of certain special circumstances (like consistently coming to sessions impaired or being in immediate risk of physical harm) I very rarely feel it necessary to refer a new psychotherapy patient for detox before I will see him in therapy.  Substance abuse, like any other defense against psychological pain, is a perfectly appropriate matter for therapeutic clarification and interpretation.  And, yes, people often come into psychotherapy in hopes that it will allow them to avoid the substance issue, but people do that with all their defenses.   No one comes into therapy to give up the things that protect him from pain.  We go into therapy in hopes that we can have the subjectively experienced problems in our lives carefully removed while leaving things essentially intact – rather like picking the fleas off a dog while leaving the dog intact.

I want to make one more point before going on to my specific discussion of gay men and some of the special sorts of pain they experience.  That is the issue of the purpose of treatment for substance abusing people.   My ultimate purpose would rarely be to simply stop the abuse.  It would be to clarify the experience motivating the abuse, and by doing that to have the abuse – over time – clear itself up.  There is a myth about that this does not work, but it happens all the time.  And there are good reasons to let it happen.  When a cause like psychological pain is corrected, the symptoms (like substance abuse) will often abate spontaneously, especially when the abuse is not a profound, addictive process, in the physiological sense of addiction.  Even then we see remarkable results, and in medicine often see that people profoundly and chronically addicted to opiates for pain control stop the medication when the pain is eliminated.   The converse, however, does not work: a cause does not spontaneously abate because one of its symptoms has been eliminated.  Stopping substance abuse, in itself, rarely corrects the problems that motivated it in the first place.   The individual – psychologically or physically – experiences and expresses the pain in other ways, a process called “symptom substitution” in psychology or medicine.   We see this is ex-abusers of one substance who switch to another, or switch to a compulsive behavior that doesn’t involve substances.  This “substitution” is one important reason that we have seen such a proliferation of twelve-step programs, including those for so-called sexual “addictions” (a topic to which I will return later in my talk).

Why then, is there so much focus on stopping a symptom?   I think there are two important reasons.  The first is that society doesn’t really give a hoot about the psychological foundations of substance abuse and is not willing to pay to address them.  The subjective quality of human life is much less important than the functionality of an individual.  In more specific terms, we don’t much care if a man goes home feeling quite miserable as long as he shows up for work reliably and gets the papers in the right file folder.  These are the reasons that society pays for substance abuse treatment, and while this may make sense to an economist – or a politician – it shouldn’t be the concern of a mental health provider.

A second reason we have focused such attention on symptom abatement brings us back to the matter of moral stigma.  While a disease model for substance abuse may have extricated the abuse from its destructive moral burden, the idea that this “disease” might be a consequence of psychological pain seems, to many, to push it right back into the province of moral issues, albeit of a different sort.  Psychological distress is much less acceptable than physical distress, a fact we see expressed all the time in the somatization of psychological problems, and in the still not uncommon reluctance of people in psychotherapy to tell others they are doing that (and I’m not talking about New Yorkers now, because Woody Allen has made it clear that they’re all “in therapy”).  Disease is still much more acceptable than feelings, and among gay men, we are now seeing an acceptance by family, society, and Elizabeth Taylor that was never extended when men were merely homosexual – and often suffering quite badly in psychological ways for that .   If substance abuse is a response to feelings – and particularly long-standing, developmentally based ones – then blame, responsibility, guilt, and victimization seem to get reintroduced into a discussion that we hoped could be as “simple” – which is also to say as meaningless – as, let’s say, ulcers or back pain.  Those of us working in mental health must help put meaning – and its human richness – back into human life rather than collude with a scientific reductionism that would seem to offer the possibility of medical interventions for any and all occasions.

Gay men have always had more than their share of psychological conflict simply for the fact of being or becominggay in a society that is largely condemning.  And for those gay men living through the last decade, the epidemic has not helped one whit.  It is my clinical experience that gay men as a group live with an inordinate amount of depression, isolation, loss and longing, guilt, and sense of failure about human relationships, and that these feelings are responsible for the inordinate amount of substance abuse that we see among gay men.

Such developmentally rooted feelings – and their complex connections to the experience of the epidemic – are seen in the words of “Alberto,” a 28 year old psychotherapy patient who had come into therapy about two years before to work on his identity as a gay man.  Chronically, but only moderately depressed, Alberto had gone through several periods of alcohol and cocaine abuse in his late teens and early twenties, and we had repeatedly talked about this as an effort to self-medicate a depression and loneliness that at times felt  unbearable.  Prior to the following session, Alberto and I had talked for several weeks about his “standard” masturbation fantasy, one that had persisted since adolescence.  It involved having sex with the same, idealized man, a fantasy that seemed to incorporate all that he longed to be connected to sexually and emotionally, and all that was also, of course, forbidden.

It’s been so much a part of experience ever since I started masturbating that I’ve never noticed it before.  But I just realized a few days ago that right after I come, I feel terrible grief.  I just never noticed it, but when I think back, that’s always been the case.

I asked Alberto if this happened when he had an orgasm having sex with someone else.

Not as much with someone else – sometimes.  But masturbating, it’s always true.  I suddenly feel sad, and sometimes if there is something bad going on in my life, I’ve started crying right after I come.  It’s just this intense sadness, really a feeling of loss, and I may attach it to something else going on, but I think it really comes from my sexual fantasy somehow.

I asked Alberto what he thought the feeling of loss was connected to.

It’s that he disappears, I think.  When I was a kid, it was only when I was masturbating that I could have him.  I mean, I knew that I could never really have sex with a man, and I had this relationship with this beautiful man in my fantasy, which was the only one I could have, and when I came, he would be gone.  It’s as if every time I come, some part of me also dies, and I have died a thousand times by now.  Since I’ve come out, and I really am having sex with men, then I just bring this sadness along, because the sense is that this is still not something that you can really have, and that somehow you are going to lose this just the way I’d lose the fantasy.  It’s very mixed up.  I have said to myself sometimes, particularly with Dan, when we were together, “This is someone I love very much, and your sadness is not about him, that is not what’s going on here.”  You know, “This is Dan, and the sadness is about something else, something old.”

The experience of loss and longing that we hear in Alberto’s words is characteristic of many gay men, and is connected to a series of very typical developmental events that underlie sometimes lifelong feelings of loss, nostalgia, and depression.  The most central of these “events” is coming out , an immensely complex psychological and social process that is, in many senses, itself a lifelong experience.   Most gay men have, at some point in their lives, made attempts to be heterosexual.  This may be a quite literal attempt or it may be expressed more subtly in the five year-olds effort to play with “approved” toys rather than the ones he feels like playing with.  This is an effort to be who people expect him to be, and very few, if any, children are so self-possessed or clarified in their identities that they are insensitive to such expectations.

This means that by late adolescence the typical gay man has gone through many false starts and elaborations, and, often, the relatively complete development of a psychological and social false self.  Loss is thus first experienced in the homosexual child as the unattainability of a real self , for this is a self connected to forbidden feelings.  As one grows further and further into a false heterosexual self – something that is thankfully becoming less common because of increased social acceptance of gay adolescents – the real self recedes further and further from the individual’s internal and social lives.  When the individual does finally begin a coming-out process, it is because the feelings of loss about the real self have finally become unbearable and unmanageable.  The typical intensity – and often excesses – that we see in people coming out expresses, in part, the intensity of drive to unite with what has been lost for so long.  We can, and do, experience loss about things we have never had.

Although the ultimate consequence of the coming-out process will, we hope, finally be constructive and integrating, there are still other losses along the way.   These are losses about the products of the false self: feelings, relationships, and, often, an entire way of life, much of it important and authentic, even if built on “false” premises.  The gay man finally coming out must often give up his partner, children, parents, and social network; and importantly he must give up who he, in part, really was , which is to say, the person he was expected to be and who was loved and respected for that.   Very few gay men recover entirely from feelings of loss about either the true self or the false self, these feelings lingering throughout life, as Erik Erikson once put it, “in our dependencies and nostalgias, and in our all too hopeful and all too hopeless states.”

The interaction of the AIDS epidemic with such personal histories is very powerful, for it is an event that, above all else, must be characterized psychologically as about loss.   In the last ten years, the gay community in San Francisco has lost more men than all the San Franciscan’s lost to the four wars of the 20th century combined and quadrupled.   This is not the community that needed such new sources of loss.   The magnitude of epidemic-induced loss, isolation, and depression – often in combination with developmental predisposition – is seen in the flourishing of twelve-step programs for gay men over the past several years, programs for every possible behavior.  While many of these programs have made important constructive contributions to the lives of many gay men, there are also elements of this trend that trouble me.  The programs too easily support interpersonal isolation, an abandonment of emotional intimacy, and homophobic feelings, all in the guise of supporting “clean and sober” lifestyles.

Regardless of where gay men perceive themselves politically, many have become heirs to the “just-say-no” Republicanism of the eighties.  Though the tide is turning with Clinton’s election, on the whole, we have taken a very hard turn away from the artistic and the sensual towards what I can only call a kind of ascetic “economic sobriety” that seems to value contribution to the gross national product above all else – and certainly above the humanistic, personal, and often sensual and sexual, exploration that we valued in the seventies.  Gay men have become part of this trend not only in the general run of things, but as a group with some special, destructive and often unconscious baggage: the perception that the epidemic is retribution for the energy and exploration of the seventies and that reparations for those transgressions may be paid for with a new especially sober – in the broad sense of that term – approach to life.  We have become so sensible and serious

The coalition of pressures that brings men to the twelve-step programs is a compelling one: a frightening epidemic, a broad social asceticism, and, for many, real problems with compulsive sexuality or substances.  But when the programs are used not only to change destructive behaviors, but to pay retribution through abstinence for irresponsibility, failure, or mistakes – whether these be about substances or sex – then there is an element of self-punitiveness that expresses underlying homophobia.  Related to the paying of retribution through abstinence is the use of the abstinence to bury psychological issues – both those that are long standing and those that are more epidemic-induced.  Thus guilt about one’s homosexuality – or sexuality, period – may be addressed symbolically by adherence to the schedules, disciplines, and prescriptions of the programs.  One may be worthy and accomplished despite being homosexual.  I have seen a number of psychotherapy patients over the past years who have used programs to avoid long-standing, epidemic-exacerbated conflicts about intimacy and relationships; and they have done this by engaging their compulsive character trends – “addictive personalities” in twelve-step parlance – in the more rigid and prescriptive elements of the programs.  When the programs are thus made into an alternative to the examination of feelings, an alternative to psychological growth, or an alternative to intimacy, then they are contributing to the gay community’s long-standing and epidemic-induced problems with isolation.

The example of a psychotherapy patient whom I shall call “Kevin” will illustrate what I am talking about.  Kevin was from a very pious Catholic family which, though Kevin had come-out to the many years before, continued to deny or ignore his homosexuality.  Partly because of his own sense of being out of control with alcohol and cocaine, and partly at his parent’s urgings, he went into recovery with AA in the late eighties.  It seemed clear to Kevin that his parents, having long ago given up on his failed Catholicism, privately felt that AA would not only deal with his substance abuse, but his homosexuality as well.  Though Kevin had no such conscious purposes, he was conscious of exploiting their confusions to soften their antagonism about his sexuality.  Kevin had been clean and sober for three years before coming to see me about his perception of “relationship problems.”  He had had no relationships for the previous three years and only an occasional, anonymous sexual encounter.  Although Kevin considered himself “sexually addicted,” his history did not support the contention.  His anonymous sex had begun in adolescence when this was his only sexual opportunity.  In later life he continued anonymous sex, though rather sparingly, and I felt that this form of sex had more to do with conflicts about his sexuality and with intimacy than with a compulsive process.  Anonymous sex kept sex out of his emotionally intimate relationships and thus kept those relationships free of the sexual feelings that so conflicted him.  After about six months of therapy, Kevin met another man, “Tom,” and the following notes are a condensation of several weeks of therapy.

I’m really in an incredible state – I’m completely disorganized, confused, and I don’t know what – it’s unbelievable, but my head is spinning.  Tom and I had sex on Friday night.  This is the first time in years, and the first time since I’ve been clean and sober.  It was very intense – I mean, it was incredible, it was wonderful, but it was very scary.  I got up at six-thirty Saturday morning, went home and changed my clothes, and before my regular [AA] meeting I went to an SLAA [Sex and Love Addicts Anonymous] meeting.

I asked Kevin why he went to the SLAA meeting.

You have no idea how I was feeling.  I was feeling completely out of control.  I haven’t felt like that in years, literally years – since I was using.  I feel overwhelmed, out of control just talking about it.

Over the next weeks, I repeatedly wondered about Kevin equating his strong feelings for Tom with “being out of control.”  Kevin continued to feel anxiety about his feelings about both Tom and me (because of my questioning), and he increased his AA meetings from four weekly, to 9 or 10.  I interpreted this is an effort to spend less time with Tom, who had already expressed feeling “second fiddle” to Kevin’s meetings.   The AA schedule also allowed Kevin to pull back from the therapy and Kevin suggested that we reduce our frequency of meeting because of his schedule.  I said that I thought he was trying to reduce his feelings of dependence and intimacy with me.  The AA meetings consumed a great deal of time, dictated his schedule, and substituted a social environment that reduced his needs for both Tom and me.  I also felt the meetings provided a framework in which his frightening feelings could be organized into a “pseudo interpretation” about addiction, an interpretation in which being of control was about an impending relapse into drug use.  Because this interpretation did not address the real anxiety about intimacy, the anxiety continued to worsen and Kevin needed more and more meetings.  Such a cycle precisely describes compulsive behavioral solutions.  Kevin’s response to these ideas was that neither Tom nor I “approved” of his AA meetings and that he wanted more support for his efforts.  He felt endangered by Tom in other ways too.

Tom makes me feel very out of control, and I can tell you when I realized this.  We were making love one night – well, having sex anyway.  No, we were making love.  You know, he’s negative too and this was the first time it came up, but he said that he would like to fuck.  I said yes, though I didn’t know who would be on top, and he asked me if I had condoms.  Well, I realized that I wanted him to fuck me and I wanted him to it without a condom, and I had this rationale that he was very conscientious about his health and has been tested a zillion times, so that it was most likely safe.  I asked him to fuck me without a condom and he did.  I haven’t done that in years and years.  And it was wonderful . . . But what I started to tell you was, the next day, when I was thinking about what we’d done – it’s so forbidden – and I had this sudden anger at him for luring me into unsafe sex.  But then I said, “no wait a minute – it’s me that wanted to do that, it’s me that it means so much to, it’s not Tom.  It’s Tom who was asking for condoms.”  I was blaming Tom for my feelings, because I couldn’t own up to them, because I’m scared of them.  I’m scared of AIDS and what it’s done to me, what its taken from me, and I’m more scared than ever to love anyone.  I realized all this when Tom fucked me.  And I realized that I’m afraid of his dying, that I will lose someone else, and that I don’t let myself have feelings now because I’m afraid that they will be too awful.

Over a period of two or three years following this session, Kevin was increasingly able to focus on the central issues of intimacy, his lifelong sense of loneliness and isolation, on his fears of loss, and on his use of substances to try to mitigate these feelings.  Substances, he came to understand, were exaggerating and perpetuating his isolation because them kept him in a state of consciousness out of which real communication – much less intimacy – was impossible.

In summary, there are important human reasons to introduce – and I should say, partially reintroduce – psychological models of description into our approaches to substance use and abuse, particularly where disease models are obfuscating problems with homophobia, intimacy, and isolation.  Such models need not “pathologize” the problematic use of substances, and they certainly need not reintroduce “moral” issues.  What they do offer is the possibility of exploring many of the developmental, as well as epidemic-induced, psychological issues that gay men quite typically struggle with and attempt to resolve through substance abuse.  In the bargain, these psychological models offer the possibility of lives that are not only clean and sober, but rich, intimate, and worth the trouble in an epidemic that has made that accomplishment considerably more difficult to achieve.

Finally, a word about substance abuse and HIV transmission itself, a matter that makes broader understandings of the meanings of substance abuse a critical issue at this time.  There is, in some populations, a demonstrated correlation between substance abuse and unprotected sex.  But we have almost exclusively interpreted this correlation as if it were causation, and have concluded that people have unprotected sex because they’re “high.”

More psychological perspectives on substance abuse provide useful understandings about this problem.  These include the observation that people are not simply having unprotected sex because they’re high, but that they got high in order to have unprotected sex.  This understanding acknowledges that unprotected sex is often important and compelling and that the disinhibition provided by substances is often necessary to act out the desire.  It also recognizes that people also often use substances to have protected sex, either because they have long-standing anxiety about sex or intimacy, or – quite commonly – because our education has fallen seriously short of doing its work in a way that might allow real confidence about the reasonable safety – and human value – of protected sex.

Poor self-esteem is another common underlying motivator for both substance abuse and unprotected sex, and depression may also underlie and motivate both.  It is thus feelings that are often responsible for unprotected sex, and they must be addressed if behavior is to change.  These feelings are evidenced, not at the substance-impaired moment that the sex takes place, but at the moment the individual decides to use the substance.  When a man tells us that he had unprotected sex “because I was drunk,” the pertinent question is “Why did you get drunk?”   That is the question that will help us with HIV prevention, and that question, a question about psychological motivations and human meanings, is the one that we must reintroduce into our broadest understandings of substance use and abuse.