The art and science of addiction counseling

What is addiction counseling? First let's look at what it is not. It is not classical or contemporary mental health counseling. Because an ever-growing number of professionals have moved from the mental health field to addiction treatment over the past twenty years, much confusion surrounds this issue.

What was the basis for this movement? Addiction treatment, as drafted and provided by a fledgling group of recovering alcoholics, addicts and enlightened mental health professionals, WORKED! It was successful. Or, in the current vernacular, it produced positive outcomes. And what fueled these early professionals and para-professionals? It was the disease model of addiction; abstinence-based treatment; collaboration with and referral to Alcoholics Anonymous, Al-Anon and Narcotics Anonymous; and courage. Upon the shoulders of these historic workers, the current treatment system was built and expanded. They had the courage to develop a treatment approach that was not based upon mental health strategies or theories. They possessed the strength to stand up to psychiatrists, psychologists, and other highly-degreed mental health professionals who attempted to abort or divert the recovery movement. They said "no" to aversion therapies. They said "no" to controlled drinking approaches. And they said "no" to the Valium and Librium treatment models. Thus they resisted efforts that attempted to integrate addiction treatment into mental health treatment models.

Regarding the nature of addiction, there is a basic disparity between the fields of mental health and addiction treatment. James Milam, Ph.D., author of Under the Influence, outlines this disagreement in his position paper entitled "The Alcoholism Revolution," In this paper Milam states that the psychogenic model, as followed by most in the field of mental health, sees addiction as "a symptom or consequence of an underlying character problem, a destructive response to psychological and social problems, a learned behavior," In contrast, the biogenic model "recognizes that alcoholism is a primary addictive response to alcohol in a biologically susceptible drinker, regardless of character and personality."

My own professional career is an example of the difference between the treatment of addiction and the treatment of mental illness. My master's degree is in Public Service Counseling, which is similar to most of the master's programs in counseling or social work; it offers training in the provision of counseling services. I studied counseling theories and techniques and followed that with internships and work experiences that yielded additional training in working with clients. My first employment was in a family life counseling center, which focused primarily on services for the development of parenting skills. I next worked for a community mental health center with a primary focus on services to the severely mentally disabled. Later I worked more as a generalist, treating outpatients who presented with a variety of problems, such as marital difficulties, depression, and anxiety disorders.

In each of these work settings there were alcoholics, drug addicts, and family members impacted by addiction. However, they were rarely treated for their addictions. We instead tended either to ignore the addiction problem or tried to treat the addiction by approaching the symptoms of the addiction. Then, in 1981, I was introduced to the work of Milam and others, who were focusing on the disease model of addiction. I was attracted to both the research and the utility of this model and eventually devoted myself to providing treatment solely to alcoholics, addicts and their family members. I soon discovered that many, or perhaps most, of the skills I had developed in the field of mental health were not only ineffective in treating addiction but were, in fact, harmful.

Although the addicted person often presents with symptoms of mental illness, attempts to treat these symptoms as part of the initial treatment of addiction are distracting, ineffective, and potentially harmful. Any treatment that does not focus on the acute health and social issues associated with drinking and drug use is detrimental since the consequences of continued drinking and drug use are serious and potentially fatal.

I often use the example of the emergency room. If you had a loved one admitted to the emergency room with a severed artery following an accident, and you found the treatment provider asking questions about the patient's marital life, problems with depression, conflicts with parents, etc., you would probably become very upset. Although these problems may be real and even serious, shouldn't someone be doing something about the bleeding?

Alcoholic and drug-addicted clients need help first to stop drinking and using drugs. The process of stopping, however, does not mean not drinking or using for a few days. Instead, it means an extended period of time to allow the body and mind to heal from the long-term trauma experienced from addiction. Treatment strategies need to focus on the problems and challenges of sobriety. In my case, I had to learn new skills and abandon the approaches I used as a mental health professional. Because the treatment of addiction is not similar to the treatment of mental illness, the approaches, skills, techniques, and strategies must be different. So while mental health treatment should be applied to those who have a primary mental health problem, addiction is primarily a health problem. Now let?s explore some of these more significant differences.

Exploring versus Accepting Emotional States

Emotional states exist. A person is happy, sad, glad, angry, etc. Mental health counseling seeks to explore these states as a way of uncovering issues that could be beneficial in helping the client. However, the newly sober client's emotional state is too volatile to explore and is most often related to withdrawal or organic brain dysfunction associated with chemical use. Attempting to investigate these emotions and yield understanding or insight from them is futile and harmful. It is harmful in that to explore them while in early counseling suggests that the exploration will somehow maintain sobriety. Addiction treatment strives to help the client accept the presence of these emotional states, begin to recognize their volatility, and thereby stay sober in spite of them.

Medication-Reliant versus Abstinence-Based

Depression, anxiety, and mood swings are all expected symptoms of the chemically-impacted brain. Effective addiction treatment strives to attain a period of abstinence from alcohol or drugs before even attempting to determine the presence or extent of these problems. Addiction professionals who understand the biogenic nature of the disease generally believe that a period of several months is required before attempting to determine the need for treatment of other disorders. These professionals have historically been at cross-currents with other professionals regarding the issue of medication. Addiction specialists have been courageous in past efforts to educate the public and other health care professionals about the dangers of benzodiazepines, sedatives, and other mood-altering medications that may hinder or exacerbate the recovery process. Addiction professionals believe that counseling and the life-changing power of Twelve Step recovery principles are the only appropriate options for interventions into life problems.

Problem-Focused versus Abstinence-Focused

There is considerable personal and social "wreckage" when someone begins a recovery process. The number of difficulties, problems, issues, and stressors can be overwhelming to both client and counselor. There is a temptation to attempt to solve, or least address, all of these problems. And the client adds to the counselor's dilemma with his normal obsession with his litany of stressful problems. However, addiction treatment should focus on helping the client stay sober through the stress of the problems that have accumulated. Trying to address these complicated issues in early recovery, with a chemically-impaired brain which is producing varying and unpredictable emotional states, is non-productive and will generally cause an apparent worsening of the problems. Effective addiction treatment addresses the need to stay sober. It tackles only those problems that may pose an imminent threat; the counselor must decide which problems must be addressed first.

Client-Centered versus Counselor-Centered

A health care professional treating a brain-injured client in the emergency room would not rely on the client to design his own treatment plan or establish the hierarchy of services to be provided. Addiction treatment, especially for those clients in the first months of recovery, is counselor-centered, meaning simply that the counselor knows how the recovery process works and the client does not. Because of the impairment caused to mental and emotional functioning, the client needs direction and assistance to stay sober. The power of addiction, with its components of craving, lifestyle and withdrawal, is the central governing influence for the newly recovering person. The power of the addictive thought process will almost always lead to the wrong decision if the client is left to his own devices. Addiction counseling is directive, inspirational, and based upon the successful experiences of others. It is focused like a laser beam on the actions that lead to continued sobriety. As the mind and emotions heal, so does the process of decision-making improve and develop, allowing the recovering person finally to rely on and trust in his own thinking and judgment.

Promoting Dependence versus Promoting Independence

The ultimate goal of any counseling or treatment is that the client will eventually not require the service. Addiction counseling is directed toward this goal. It is abstinence-based, non-medication dependent, and realizes that the recovery process leads to healing and personal transformation, which creates a person of greater strength, confidence, ability, knowledge, and wisdom than existed prior to the onset of the crisis. It is no accident that so many recovering people are working in the field of addiction: their lives have been restored to wholeness.

Uncomfortable with Pain versus Understanding the Utility of Pain

It is very difficult to be with someone who is experiencing pain, be it physical or emotional. The symptoms of addiction are painful to experience and painful to watch. The tendency for the professional -- in fact the very reason why many people enter the field of counseling -- is to try to remove the pain. This tendency leads many professionals to go to great lengths to solve long-developing personal problems, build up the client's ego and self-esteem, or remove the symptoms with psychotropic medications. All of these efforts fail in the treatment of addiction because pain has a great utility in its treatment. Every recovering person can attest that it was the pain of addiction that motivated him to ask for help, to take direction, and to go to an AA meeting. When the counselor attempts to remove this natural consequence of addiction -- pain -- she may be inadvertently removing the motivation to stay sober. To be comfortable in the presence of the pain of addiction, the counselor must have the utmost confidence in the recovery process and his ability to promote that process. And this is where recovering counselors are so effective: they are not intimidated by the painful consequences of addiction. They are not overwhelmed by the apparent hopelessness of the situation. They know the client can recover through the pain and the problems that permeate his life.

Finally, if a miracle is an outcome that cannot be explained by the sum of all the treatment efforts, addiction treatment not only believes in miracles, it relies on them. Not surprisingly, miracles often exceed the counselor's imagination. The counselor can participate in the celebration of these miracles if he is willing to learn the skills and undergo the personal and professional development required for this dynamic and challenging pursuit.

Ten ways family members can help a loved one with a drug or alcohol problem

The pain and suffering of addiction is not limited to the alcoholic or drug addict. Family members share a tremendous burden as well. Shame, guilt, fear, worry, anger, and frustration are common, everyday feelings for family members concerned about a loved one's drinking or drug use. In most cases, the family has endured the brunt of the consequences for the loved one's addiction, including the stress of worry, financial costs, and life adjustments made to accommodate the addicted person's lifestyle. Addiction perverts the positive influences of the family. The disease twists love, concern, and a willingness to be helpful into a host of enabling behaviors that only help to perpetuate the illness.

Family and friends are usually very busy attempting to help the alcoholic or addict, but the help is of the wrong kind. If directed toward effective strategies and interventions, however, these people become a powerful influence in helping the loved one "hit bottom" and seek professional help. At the very least, families can detach themselves from the painful consequences of their loved one?s disease and cease their enabling behavior.

Here are ten ways family members can help their loved one and themselves:

1. Do learn the facts about alcoholism and addiction. Obtain information through counseling, open AA/NA meetings, and Al-Anon. Addiction thrives in an environment of ignorance and denial. Only when we understand the characteristics and dynamics of addiction can we begin to respond to its symptoms more effectively. Realizing that addiction is a progressive disease will assist family members to accept their loved one as a "sick person" rather than a "bad person," This comprehension goes a long way toward helping overcome the associated shame and guilt. No one is to blame. The problem is not caused by bad parenting or any other family shortcoming. And attendance at open AA/NA meetings is important: families need to see not only that they are not alone in their experience, but also that there are many other families just like theirs involved in this struggle. Families will find a reason to be hopeful when they hear the riveting stories of recovery shared at these meetings.
2. Don't rescue the alcoholic or addict. Let him experience the full consequence of his disease. Unfortunately, it is extremely rare for anyone to be "loved" into recovery. Recovering people experience a "hitting bottom," This implies an accumulation of negative consequences related to drinking or drug use which provides the necessary motivation and inspiration to initiate a recovery effort. It has been said that "truth" and "consequences" are the foundations of insight and this holds true for addiction. Rescuing the addicted person from his consequences only ensures that more consequences must occur before the need for recovery is realized.
3. Don?t support the addiction by financially supporting the alcoholic or drug addict. Money is the lifeblood of addiction. Financial support can be provided in many ways and they all serve to prolong the arrival of consequences. Buying groceries, paying for a car repair bill, loaning money, paying rent, and paying a court fine are all examples of contributing to the continuation of alcohol or drug use. Money is almost always given by family members with the best of intentions, but it always serves to enable the alcoholic or addict to avoid the natural and necessary consequences of addiction. Many addicts recover simply because they could not get money to buy their drug. Consequently, they experience withdrawal symptoms and often seek help.
4. Don?t analyze the loved one's drinking or drug use. Don't try to figure it out or look for underlying causes. There are no underlying causes. Addiction is a disease. Looking for underlying causes is a waste of time and energy and usually ends up with some type of blame focused on the family or others. This "paralysis by analysis" is a common manipulation by the disease of addiction which distracts everyone from the important issue of the illness itself.
5. Don?t make idle threats. Say what you mean and mean what you say. Words only marginally impact the alcoholic or addict. Rather, "actions speak louder than words" applies to addiction. Threats are as meaningless as the promises made by the addicted person.
6. Don?t extract promises. A person with an addiction cannot keep promises. This is not because they don't intend to, but rather because they are powerless to consistently act upon their commitments. Extracting a promise is a waste of time and only serves to increase the anger toward the loved one.
7. Don?t preach or lecture. Preaching and lecturing are easily discounted by the addicted person. A sick person is not motivated to take positive action through guilt or intimidation. If an alcoholic or addict could be "talked into" getting sober, many more people would get sober.
8. Do avoid the reactions of pity and anger. These emotions create a painful roller coaster for the loved one. For a given amount of anger that is felt by a family member in any given situation, that amount -- or more -- of pity will be felt for the alcoholic or addict once the anger subsides. This teeter-totter is a common experience for family members: they get angry over a situation, make threats or initiate consequences, and then backtrack from those decisions once the anger has left and has been replaced by pity. If anger can be avoided, then so can pity. The family can then follow through on their decision to not enable.
9. Don?t accommodate the disease. Addiction is a subtle foe. It will infiltrate a family's home, lifestyle, and attitudes in a way that can go unnoticed by the family. As the disease progresses within the family system, the family will unknowingly accommodate its presence. Examples of accommodation include locking up money and other valuables; not inviting guests for fear that the addict or alcoholic might embarrass them; adjusting one's work schedule to be home with the addict or alcoholic; and planning one's day around events involving the alcoholic. (A spouse recently confided that she would set her alarm to get up and pick her husband up from the bar.)
10. Do focus upon your own life and responsibilities. Family members must identify areas of their lives that have been neglected due to their focus on, or even obsession with, the alcoholic or addict. Other family members, hobbies, job, and health, for example, often take a back seat to the needs of the alcoholic or addict and the inevitable crisis of addiction. Turning attention away from the addict and focusing on other personal areas of one's life is empowering and helpful to all concerned.
    

Each of these suggestions should be approached separately as individual goals. No one can make an abrupt change or adjustment from the behaviors that formed while the disease of addiction progressed. I cannot overemphasize the need for support of family members as they attempt to make changes. Counseling agencies must provide family education and programs to share this information. They must offer opportunities for families to change their attitudes and behaviors. The most powerful influence in helping families make these changes is Al-Anon. By facing their fears and weathering the emotional storms that will follow, they can then commit to ending their enabling entanglements.

The disease of addiction will fervently resist a family's effort to say "no" and stop enabling. Every possible emotional manipulation will be exhibited in an effort to get the family to resume "business as usual," There will always be certain family members or friends who will resist the notion of not enabling, join forces with the sick person, and accuse the family of lacking love. This resistance is a difficult but necessary hurdle for the family to overcome. Yet it is necessary if they are to be truly helpful to the alcoholic or addict. And being truly helpful is what these suggestions are really about. Only when the full weight of the natural consequences of addiction is experienced by the addict -- rather than by the family -- can there be reason for hope of recovery.

I also find it very helpful to tell family members that these suggestions offer the best opportunity for the alcoholic/addict, perhaps motivating them to seek help for their problem. In the beginning, family members are extremely focused on helping their sick family member and have very little interest in helping themselves. So, a strategy of ending enabling behaviors and withdrawing inappropriate support that is designed to help their love one become more willing to seek help will be more readily accepted by the family and will provide them with incentive to take these difficult actions. The family will eventually recognize the positive effect their changed behavior is having on them as well.

Alcoholism is a disease

Alcoholism is a disease, and so are other drug addictions. The common perception that those addicted to alcohol or drugs are weaker, less moral, more prone to mental illness, inconsiderate, or deviant is false. The disease of addiction effects an individuals behavior, attitudes, values and lifestyle. The addicted person is continually and progressively losing control of their behavior, thoughts and feelings. To family, friends and co-workers, this downward spiral is both painful and frustrating to watch. To the addicted person, the disease becomes an overwhelming reality which is best described as powerlessness.

Considered first and foremost physiological problems (meaning that the disease rests in the body), the brain and liver function have been identified as the primary culprits for the phenomena of craving, increased tolerance and mental obsession associated with the disease.

Our goal is to help a sick person get well rather than a bad person get good.

Recovery from addiction requires an individual to engage in a meaningful and in-depth course of self-appraisal, education, behavioral change and commitment to activities that support and nurture their resolve to be alcohol and drug free.

Alcohol: still number one

Despite on-going discussions about the increase in drug use among youths, alcohol continues to be the most abused drug for children and teenagers. And yes, alcohol is just as much a drug as are marijuana, cocaine and other narcotics. Although alcohol is a legal drug for adults, it is illegal for youths. Underage drinking remains the major drug issue of today, even considering the rise in narcotic addiction.

A study by the U.S. Department of Health and Human Services revealed some alarming statistics: 85% of Ohio students in grades 9-12 report having tried alcohol; 30% indicate they had their first drink before age 13; and in the 30 days prior to taking the survey, 56% said they had consumed alcohol, 37% stated they had consumed five or more drinks consecutively, and 5% said they had consumed alcohol on school property.

A serious consideration regarding underage alcohol use is that it increases the likelihood of other drug use. For example, youths who report even occasional drinking are ten times more likely to use another illegal drug. We also know that the younger people are when they first experiment with alcohol, the greater the risk of becoming addicted to alcohol or another drug. This is why it is so important for us to take seriously the dangers of underage alcohol consumption. It is not harmless; it is not just "kids being kids."

Another concern involves parents who allow their children to drink alcohol in the home, perhaps even hosting drinking parties. These parents rationalize this practice by saying they would rather have their kids drinking at home than in an unsafe environment, such as an automobile. This dangerous thinking, however, fails to consider that once illegal alcohol consumption is condoned?even in the home?it will likely progress to other locations, with other people, with serious consequences.

Some common warning signs of covert alcohol use include the odor of alcohol, sudden changes in mood or attitude, loss of interest in school, sports or other activities, discipline problems at school, change in friends, secrecy, and withdrawal from the family. These behaviors should be identified and discussed openly. Parents who talk frequently and consistently with their children create opportunities for helpful intervention.

If you learn that your child is drinking, you should take the situation seriously. Share the information concerning the risks with your child, especially if there is a family history of alcoholism. Also, be prepared to indicate what consequences will be encountered if the drinking continues. If there is an incident involving other children, be quick to inform their parents. Keeping secrets never works; withholding information denies other parents the opportunity to address their own child?s behavior.

Most importantly, be the best role model possible. Because youths are especially sensitive to contradictions in adults, if the parents themselves are abusing alcohol or other drugs, discussing the risks involved in using them will be meaningless. Also remember that a child experimenting with alcohol or drugs is not necessarily a sign of bad parenting. Experimentation often occurs regardless of the skill or devotion of the parents. Our goal as parents is to be aware, be prepared, and be ready to take appropriate action.