Terminal Uniqueness
An article in the Sunday New York Times, “The Science of Making Better Decisions”, reminded us of a behavior suffered by many people with substance use disorder and their families typically called “terminal uniqueness”. Twelve Stepping.com describes this condition as “a persistent conviction that the alcoholic or addict is profoundly different, uniquely complex and that no one else could possibly understand it.”
Stephen Rose discusses this phenomenon at length in his article “What Is Terminal Uniqueness?”. The origins of such feelings for the person with substance use disorder, people with other behavioral health disorders, and their families is rooted in stigma, shame and isolation. Stigma is familiar to most of us as the case where people with behavioral health and specifically substance use disorder suffer from the remnants of American views of these issues as moral failings. Shame is associated with that stigma and the person with SUD and family members shrink from public exposure due to the moral judgment they anticipate whether or not that judgment is real. Isolation is a default if ineffective strategy as retreating from others feels better than dealing with the shame that the victims expect. These three causes tend to be self-reinforcing.
Evidence that uniqueness is incorrect is everywhere. We have discussed that there are estimated to be 40 million people with a substance use disorder. Overlapping are some 50 million people who may fit the criteria, or not, who are heavy drinkers or binge drinkers. We could debate at length about the one-third of the 37 million cannabis users who become dependent. We also discussed how relapse in SUD is not unique and is similar and, in some cases, less than other chronic diseases such as type 2 diabetes and cardiopulmonary disease. Of course, if facts overcame behavioral health issues, even when they are accessible, treatment would be much easier and more often successful.
In the New York Times article Emily Falk describes how this phenomenon applies in everyday life not just in behavioral health. “In brain scans, neuroscientists like me can see these processes unfold. Rewards that are far in the future, situations that are geographically far removed or events happening to someone else are all represented in similar ways; future you is akin to an acquaintance. The less vividly we imagine a reward, the less weight it gets in our value calculations. But when we try to motivate ourselves, we often focus on long term rewards rather than nearer-term rewards. We’re working against our brains when we try to motivate ourselves this way.”
When someone is struggling with life’s challenges, something other than SUD, they tend to default to a non-productive framing of the situation and the approach. Further implied in Dr. Falk’s description is that the individual does this not with others but alone. To be certain, the physical aspects of SUD, the brain linkages, are a major factor in denial as is common with the patient. Withdrawal creates additional pressures after a decision to recover is taken. However, the sense that the SUD patient and their family are unique in making decisions is further undermined.
Interestingly, Dr. Falk describes a solution she found to her feelings of uniqueness in a particular crisis. She found common ground with her research team and participated in with the group working through the issue. “When we imagine we’re acting alone, we give up one of the most important and powerful sources of reward and resilience: our connections to others. Our brains are equipped with a social processing system that is engaged in thinking about other people’s minds and helps us understand and connect with them — including people who have labored on similar causes before us. When we feel connected, it immediately produces activation in the reward system and changes our value calculations.”
Of course, Dr. Falk and her team developed a self-help group with behaviors not unlike a twelve step approach. The person with SUD, having made a decision to deal with the issue, or perhaps more difficult being forced to confront the situation, systematically cuts themselves off from the most crucial elements of recovery including widely available support groups, specifically AA, NA, Al-Anon et al. Even when physically present in self-help the person with terminal uniqueness remains emotionally absent. Instead of listening for similarities and identifying with the shared feelings of others, they engage in a process of comparison, noting differences that sets them apart.
Recovery as currently defined is very much a journey of connection, and addiction thrives in the isolation that terminal uniqueness creates. In the process the individual denies themselves access to community, shared experience, and the external support that is part of recovery. Furthermore, an individual convinced of their own exceptionalism will reject the collective wisdom of the recovery community. They will dismiss evidence-based therapies thinking that these solutions could not possibly apply to their uniquely complex case. Identification and the breaking down of uniqueness that is key to recovery through twelve step communities never occurs.
Dr. Falk’s report also tells us that a widely held belief of difference, if not uniqueness, among the SUD community, and particularly the recovering community, is also not real. Alcoholics, other drug addicts and their families have many of the same experiences as people with other behavioral health concerns, people with physical diseases and people in stressful if less permanent situations. It is possible that setting themselves outside the main stream, perhaps even as special, works to promote recovery as something rare and to be cherished. Perhaps, though, this specialness works to encourage uniqueness which can work against recovery by encouraging people to avoid those tools that would help them in the first instance. This is a disease as defined by the AMA in 1956. 40 million people suffer from the disease. The individual and their family suffer from a disease, not a moral failure, and they are far from unique.
Estimates are that among the 40 million American adults with a substance use disorder only 6% achieve recovery if measured by one year’s abstinence. While this does not qualify as unique it does suggest that successful recovery is rare. While the process that leads to the feeling of uniqueness is understandable, it is not the case. The sooner the person with substance use disorder and those codependent come to this realization the sooner the tools of recovery can become effectively available to them.
Gene Gilchrist
Louisville, Kentucky
