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.