The Question of Identity

Disclaimer:  nothing in this post should be taken or held as clinical instruction, clinical supervision, or advisory concerning patient care. 

The phenomena of struggling with one’s own identity is an associated feature of addiction illness.  Did you know addiction illness has this associated feature?  Until last Fall, I didn’t. 

For the individual patient, this difficulty can be observed across any or all of the SUD course of illness, treatment, and recovery.

Last year when I read some journal articles describing a brain region associated with the function of one’s sense of self, and the problems that arise from substance use damaging this area, a number of things I’ve seen in my clinical work clicked into place.

Once I caught onto the concept I reflected further and did some digging.  It turns out that difficulties with one’s own sense of self in the SUD context have appeared in:

1. Decades of my clinical observations;
2. Recent empirical research;
3. Literature from a mutual aid fellowship; and
4. Struggles I have noticed in the professional part of the field.

This post will cover each of those four sources of information in order.  And before we dig into this, I’ll say that in my opinion, if all four of these sources align on any topic, I’ll probably take that topic relatively more seriously.

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1. Sourced from clinical observations

Over the years of my clinical work, patients have said to me, or asked me, things like:

I remember who I was before I ever started using.

I didn’t like who I was becoming.

I wonder who I am, now that I’ve stopped using.

If I get better, will I still be me?

As these have been put to me, they seem to point to a few things:

• A real search for understanding self within a given point in time;
• A certain kind of discontinuity of self over the long arch of time;
• Wondering about self, relative to specific stages (e.g. before the onset of use, before the onset of illness, during course of illness, during stabilization, and during future wellbeing not-yet lived).

When I’ve met with patients over the years, some have indicated they are now sober long enough to look back and wonder who they even were prior to using the first time.  And they also try to make sense of “self”:

• in terms of who they were during the time they were becoming sicker and sicker;   
• in terms of who they are now, today; and
• who they will be years from now during future, imagined recovery. 

At this point in my clinical career, I can say the experience of being presented with those kinds of statements and questions has not been unusual. They have never been very frequent, but have always been routine.

I can also say that my understanding of and response to this kind of content in the first 5 years of my clinical career was not the same as my most recent 5 years.

I wonder what kinds of clinical experiences the reader has had that now, upon reflection, seem at least partially rooted in this difficulty within the patient experience?

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2. Sourced from empirical research in cognition and neurology

Some harms of use impacting neurocognitive function are well known and commonly recognized among addiction professionals.  For example:

• Altered function in “executive” domains of attention, inhibition/regulation, working memory, and decision-making are well-known in serving as a hallmark feature of substance use disorders¹.
• Substance use-related cognitive problems associated with “top-down” regulation of downstream motivational processes involving reward, incentive salience, stress, and negative affect are also well known¹. 

But until recently I didn’t know empirical research showed difficulties with a stable sense of self can stem from a defect in neural functioning caused by substance use.  This is a defect in the area of the brain responsible for memories that comprise who we are to ourselves. 

We all might wonder at some point in our lives, “Am I the same person across my lifespan?”² 

That’s a question that might be asked by anyone.  After all, we do seem to change and grow over our lifespan.

But struggling with and literally asking, “Who am I?” is a different question.  

At this point the reader might be wondering what neurocognitive function damaged by using leads to difficulties with one’s sense of identity?

• Some less well-known impacts of substance use include brain regions that underlie declarative memory (those memories that define an individual) and without which it would be difficult to generate and maintain a concept of self³.  
• Other less-known substance impacts include those upon regions that are involved in implicit processes that precede cognition (precognition) and supersede cognition (social cognition); these have received relatively less attention but are important features of substance use disorders¹.  
• Collectively, these less-well known areas of cognition impacted by substance use relate to implicit cognitive processes and phenomenology of personhood.

I wonder what empirical work the reader has come across (research articles, summary review papers, etc.) that also describe these difficulties?

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3. Sourced from mutual-aid literature

Perhaps we can take a hint on this topic from a portion of the Narcotics Anonymous literature:

“After years clean, we experience ourselves differently than we did in the beginning.  As we develop an identity beyond “addict,” we wonder whether that label still applies, whether we still belong in the fellowship.  We tend to learn balance by bouncing off both extremes.  Questioning our relationship with NA can take it to a deeper level.  The answers we find help to resolve our new reservations, and the security to question our foundation is part of the secret to solidifying it for a lifetime.”⁴

I include that example in this post because it is my personal favorite on this topic (for a number of reasons).  I wonder what passage in any mutual aid literature the reader knows of that also describes this difficulty of one’s sense of self? 

I find it interesting that this reading portion addresses this difficulty directly and productively.

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4. Sourced from struggles in the professional part of the field

I now ask the reader, “Who are we as a field?” 

I’m aiming that question at the collective identity of the field – our identity in the aggregate. 

That is to say, I think I see this same struggle manifested at the level of the whole group, the “we”, not just one individual patient from time to time. 

If some of the people we serve struggle with identity as a function of their illness, then the presence of this struggle at the level of the whole field itself is no surprise to me. 

And it seems logical to me that this struggle with identity at the level of the whole field might be getting worse in recent years, while we watch the normalizing of using as a part of “recovery”.  Some sectors of our field are even normalizing using as a general approach to care for those we serve with severe, complex, and chronic addiction illness.  Thus, if using as a part of recovery becomes more and more common, I would expect we will see this difficulty more and more clearly more and more often, up the chain of command in our field, over time. 

• It seems our field has its work to do in deciding who we are as a field, and where we need to go collectively. 

In the meanwhile, the field seems to be foundering⁵ in:

1. Not defining its nature (its identity);
2. An increasingly diffuse or vague purpose;  
3. And attempting to be all things to all people

I wonder if this foundering may be a manifestation, at least in part, of this specific defect. 

Given that social media is a dominant landscape, the pooling of this functional defect (along with its related confusion) is clear to see.  And in that social media context it seems this confusion as a basis for a world view and method of helping has gained weight and momentum.

Bill Stauffer has recently provided a window into the context and challenges we currently face while our field struggles with its own identity⁶.  It’s an interesting read.

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Are there take-aways or clinical applications?

In this context I wonder, “Can the researchers, clinical professionals, advocates, and those working in SUD policy come together, form a wider consensus, and lead coherently?” 

• Some people needing to identify, or needing to not identify, might be grateful if we did. 
• If we did, we might stand on firmer ground, yet also in a wider space, and therefore be better at individualizing care across a wider array of approaches. 
• And if we did, we may be less inclined to provide advice against various recovery pathways and their identities.

Has every patient I’ve worked with voiced such a struggle with their identity to me in one way or another?  Not most.  But many have. 

With my more recent learning on this topic, I find myself once again considering the importance for some people of finding a recovery fellowship – any fellowship.  But one that provides:

1. mirroring;
2. being understood;
3. understanding others;
4. and attachment and connection;
5. while one’s “identity” can remain an open question.

Knowing that declarative memory is associated with a sense of personal identity, rooted in self, and the generating of concepts of self via recall, I consider with awe the power of identifying with others and of feeling like one’s self again. 

For such individuals, the power of human community within a social structure centered in

• identification and
• commonality despite differences

is probably more healing than our science can currently show or tell us. 

I have seen that time and time again in specific patients over many years.  And now, on this topic, in that way, it seems to me it’s time for our field to catch up with our patients.

I’ll close by saying that in this context, while we add the re-popularization of holding dissociative agents, psychedelics, and amnestic agents as medicines to treat substance use disorders, I am more interested than previously in this topic.

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References

¹Ramey, T. & Regier, P. S.  (2019).  Cognitive impairment in substance use disorder.  CNS Spectrums.  24,102–113.

²Rubianes, M., Munoz, F., Casado, P., et al.  (2020).  Am I the same person across my life span?  An event-related brain potentials study of the temporal perspective in self identity.  Psychophysiology.  58:313692.

³Gould T. J. (2010). Addiction and cognition. Addiction science & clinical practice, 5(2), 4–14.

⁴Narcotics Anonymous (2012).  Living Clean:  The Journey Continues.  (pg. 29).  Narcotics Anonymous World Services, Inc.

⁵Schwartz, J.  January 19, 2022.  Substance Use Disorders as a category.  Recovery Review.

⁶Stauffer, B.  June 17, 2023.  Portraying Abstinence Recovery as Puritanical Is in the Interest of Those Who Sell Addictive Drugs.  Recovery Review.

Suggested Resources

Dunkel, C., Kelts, D. & Coon, B. (2006).  Possible Selves as Mechanisms of Change in Therapy, in C. Dunkel & J. Kerpelman (Eds.).  Possible Selves: Theory, Research and Application. (pp. 186-204).  Nova Publishers.

Kurtz, E. & Ketcham, K.  (1993).  The Spirituality of Imperfection:  Storytelling and the Search for Meaning.   Bantam, Revised Edition.

Northwest MHTTC.  What does lived experience really mean and why is it important?  May 18, 2023. 

Solms, M.  (2021).  The Hidden Spring:  A Journey to the Source of Consciousness.  W. W. Norton & Company, Inc.  NY.

Solms, M, & Turnbull, O.  (2003).  The Brain and the Inner World:  An Introduction to the Neuroscience of Subjective Experience. Other Press.

White, W. L.  (1996). Reconstructing One’s Story.  In:  Pathways:  From the Culture of Addiction to the Culture of Recovery.  Pps. 422-425.  Hazelden:  Center City, MN.