The Intersection of Adoption and Addiction

Studies have shown that individuals who have been adopted are almost twice as likely to develop a Substance Use Disorder as those who were not adopted.[2] In treating substance abuse, a variety of factors contribute to the unique manifestation of symptoms in each individual receiving treatment. Biological factors (e.g., parental substance use history) and environmental factors (e.g., criminality and divorce in the adoptive family) have been found to be difficult to parse out, in terms of their overall impact on the presence of substance use.  This is due to the fact that there are often significant overlaps between the two categories of factors.[3] Whether it is the presence of comorbid disorders, family discord, or attachment-related issues, there is often a lack of clarity regarding how each of these factors, if any, contribute to increased substance use in adoptees.[4][5][6] Thus, in treating adoptees with SUD the “why” becomes less important than the “how” of treatment methods.

Adoption and Substance Use Disorder

While addiction is a disease of escapism, it is also a disease of attachment. Researchers exploring the relationship between attachment and substance use have noted that those with attachment insecurity are at higher risk of an SUD, while also noting that particular patterns of attachment insecurity are linked to specific substances (e.g., fearful avoidant attachment patterns in those who abused heroin).[7] Alcoholics Anonymous often speaks of the “God-shaped hole” that addicts can struggle with. Miguel Caballero, who pioneered Alcoholics Anonymous for Adoptees (AAA), writes about the “mom-shaped hole” that is often unique to adoptees who struggle with addiction.[8]

For each adoptee struggling with SUD the starting point in treatment is their attachment health, or more specifically, their attachment fears. When adoptees crave attachment but also view it as the greatest threat to their safety, they often look for ways to soothe or distract themselves from this fear. Whether is it the solo user who isolates, or the user who crafts a “substance using family” for themselves and assuages their attachment fears by getting high, adoptees who abuse substances are looking for a way to feel some form of attachment.

Isolating users are dealing with the loneliness and depression that comes with fear-based isolation and detachment by artificially raising their mood or distracting themselves from their oppressive emotions by getting high. These adoptees often present with a blanket mistrust of the world and a very low bar for rejecting the attachment of others. They operate under a “separate but safe” mentality, often without insight into how this pattern is self-perpetuating and stems from their attachment fears. Substances often become an attachment figure for them, and the idea of sobriety can be terrifying, not only because they have to face all of the things they have been running from, but because they are losing their most consistent attachment object.

Adoptees who use with others use substances as a tool to form superficial attachments to those around them; substances allow them to quiet the voice of fear that pushes them to be mistrustful and run away. These individuals often form “using families,” groups of peers tied together by their substance abuse. Sobriety for them also means a loss of attachment, as once you remove substances from the using family, that family falls apart. These individuals operate under a “something is better than nothing” mentality, when in reality having relationships that lack depth and vulnerability only highlights the adoptees’ inability to connect and their grief about not having their attachment needs met. In each case, and in cases that do not fall in these two categories, we see adoptees using substances as a tool to help them face a fear they see as insurmountable. As clinicians, it is vital to remember that this is what substance abuse is so often about.

Inauthenticity

According to the father of Gestalt therapy, Fritz Perls, inauthenticity occurs when “there is a big area of fantasy activity that takes up so much of our excitement, of our energy, of our life force, that there is very little energy left to be in touch with reality.”[9] When looking for a starting point in treating adoptees with SUD, I have found that inauthenticity is the most universally applicable starting point to dismantling the behaviors that keep them in their attachment-based fears. For adoptees, their reality often feels disconnected and confusing, and so they look to craft a version of themselves that is both safer and more accepted by those around them. Often, this inauthentic persona has been building since childhood and has acted as a consistent security blanket. While inauthenticity is often aimed at making us more likeable to others, at its core it is a protective mechanism. If I am rejected while I am being inauthentic, I do not feel that it is a true rejection because I was not being my true self. Inauthenticity allows adoptees to stay separate but safe, even when they are around and engaging with others.

There is, understandably, a lot of fear associated with letting go of inauthenticity. For adoptees, the process of letting go of this lifelong defense mechanism can bring up some fluctuations in behavior that needs to be monitored in a treatment setting. For each piece of vulnerability or insight the adoptee gains, there can be an opposite behavioral outburst. I have dubbed this the “yo-yo effect” in my own practice. It stems from the conflict between the desire to be more authentic and lay down the exhausting burden of inauthenticity, and the fear of facing reality without a primary defense mechanism. Clinically, it is important to help adoptees ride these behavioral waves and continually push through towards continued insight and vulnerability.

For Clinicians

Personally, I have found Gestalt therapy to be highly effective with adoptees in general, and especially with authenticity work. I find its emphasis on authenticity comforting and refreshing as it meshes perfectly with the uniqueness of the adoptees I work with as well as all the other clients I see for SUD. The most important tenet of Gestalt therapy is its emphasis on the authenticity of the clinician. This can be an uncomfortable experience for a lot of clinicians as we are often taught to keep ourselves separate from the therapy room for fear of placing our biases or countertransference on the client. I believe it is unethical to ask something of our clients that we are not willing to do ourselves—and with adoptees, this is doubly important. We need to model and be a safe place for our adopted clients to explore moving through their inauthenticity, a process that for many has been one of their greatest fears.

In addition to maintaining your own authenticity, when working with adoptees in SUD you must become comfortable with being an attachment figure for them, albeit a temporary one. As you push them to be more and more vulnerable and authentic, you are also modeling what healthy attachment, including boundaries, looks like. There is a level of intimacy that occurs when working with this population that can often be uncomfortable and difficult to navigate. For example, these clients may become overly sensitive to perceived rejection/abandonment by clinicians. This could occur when a session time must be changed, or a client feels they need to speak with a clinician urgently while the clinician is in another session with someone else. It could also occur when a clinician seeks to initiate termination or to reduce the frequency of sessions. This level of intimacy can also be uncomfortable for clinicians because we are often explicitly taught not to allow that kind of deeper or “boundary crossing” intimacy with clients. It is important to use your own clinical support system to navigate this, and to check with your professional peers to help keep the therapeutic intimacy with your clients at an acceptable, productive level.

Unfortunately, there is not much education and training on how to treat adoptees with SUD. I personally offer training programs to agencies and treatment centers, but even those are largely based on my own experiences and models for treating this population. Research on which treatments are effective and which factors influence SUD presentation in adoptees is severely lacking, and as a field we seem to be flying blindly with the best intentions. The most important thing you can do as a clinician is treat this population with openness and authenticity and be willing to meet the client in their fear. Adoptees in SUD may take more effort and more time than the non-adoptee population and will most likely need more treatment overall. Be active in curating resources for your clients that feel authentic and helpful to you, and refer them out if you think you are not the right fit. Ask adult adoptees in recovery from SUD about their experiences and be open to the uniqueness of each adoption and addiction story. Be curious and stay curious. The work is worth the outcome.

A Note for Families

Addiction is a scary word. It conjures up images of injury, homelessness, irreparable damage, and death. While all those things are very real consequences of addiction, the association between addiction and these terrifying visuals often pushes us to treat an addict with fear, aggression, guilt, and panic. Parents will often ask, “Where did I go wrong? Don’t they understand what they are doing? Why can’t they just stop?” We might feel betrayed by our loved one, scared for their lives, and angry because we do not know what else to feel. While these are all valid emotions and responses to the life of your loved one being threatened by a disease, this is not a standalone disease. Rather, it is a symptom of underlying pain that should be treated with compassion. “Scared straight” does not work, and in many cases increases the rates of substance abuse in those who are exposed to such programs. Even the D.A.R.E. program, which was once the staple of American anti-drug education, was shown to increase rates of substance abuse in children exposed to it.[10] We know that reacting with anger, shaming, and guilt does not stop addiction from developing.