Counseling Addicted Families

A Sequential Assessment and Treatment Model

Gerald A. Juhnke, W. Bryce Hagedorn

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781317674290
• Edition: 2
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Counseling Addicted Families, Second Edition, is an up-to-date treatment manual that fosters lasting change for families dealing with addiction and addictive disorders.

Focused around the clinically esteemed Sequential Family Addictions Model, the book guides counselors through the principles of how to "progressively sequence" a client family during their change process, and explores how family counseling theories and interventions can be applied in treatment settings. This second edition aligns with the DSM-5 Substance Use Disorder criteria and terminology and includes new sections on neuroscience and cutting-edge drug detection assessment methods.

Both experienced and entry-level counselors will appreciate how the Model improves their clinical skills and knowledge to address the idiosyncratic needs of each individual family system and create healthy systemic change.

1What Is Addiction?

With Gulnora Hundley

Learning Objectives

After reading this chapter, you should be able to:

• Define “addiction” using both lay and clinical definitions
• Distinguish between chemical and process addictions
• Recognize how the Addictive Disorder definition fully encompasses chemical and process addictions
• Understand the Neuroscience of Additions
• Recognize the impacts of addiction on the family system

Introduction

As was noted in the preface, the goal of this book is to provide a practical, hands-on, clinically founded text that will help you facilitate effective family-based addictions counseling. If you have chosen a vocation focused on helping addicted persons and their families, we commend you on selecting a most fulfilling, and at times, very challenging career. Conversely, if you were “thrown into” addictions counseling either by your clients’ needs or by the agency or school in which you work, we sincerely welcome you to one of the most rewarding careers that focuses on helping systems (i.e., families) in need. But before we get too far into the application of strategies and techniques, it is important to lay the foundation for the challenges that lie ahead. This foundation will be addressed in this first chapter. Here we will begin by wrapping our minds around defining a disorder that has proven to be somewhat ambiguous and fluid: addiction—a clinical disorder that impacts every domain of individuals’ and family’s lives. Next, we want to introduce readers to the neuroscience behind addictive disorders with the hope that this information can serve as a springboard to using an integrated (i.e., multi-discipline) approach when it is warranted. Finally, and perhaps most importantly, we will explore the devastating impacts that addiction has on the “family,” defined herein as the collection of individuals who live and interact together. The foundation laid here will establish the need for competent and capable counselors to forge comprehensive treatment strategies in their work with addicted individuals and their families.

Addiction—A Working Definition

What exactly does the term addiction mean? An accurate definition depends not only on who is asking but also on the existence of established criteria for the common set of thoughts, feelings, and behaviors that underlie these disorders. We’ll begin by taking a brief look at how we define this disorder, disease, or syndrome and how this definition can be at the same time accurate and contextual for those seeking answers. Then, through a review of the current clinical and diagnostic literature, we will explore the most appropriate means for detecting the disorder’s familiar and distinguishing features. We will conclude this section with a call for a more general understanding of addiction that moves beyond the concept of chemical ingestion.

Helping Clients and Families Understand

We have found several commonalities in our work with addicted clients and their families. At the forefront of these is the desire for clients to understand what is happening to them and to their loved ones. Whereas a clinical definition may be useful to bolster comprehension and insight, we have found that non-technical and client-centered explanations tend to have more “understanding power” at the outset. One such popular lay definition that we have found useful was adapted from Nakken (1996), who stated that addiction is an abnormal love and trust relationship with an object or event in an attempt to control that which cannot be controlled.

This definition is fairly easy for clients to understand for several reasons. First, most recognize how relationships are supposed to work. For example, many believe that a relationship occurs between two people and that this relationship should be based on reciprocal respect, love, and trust. At the same time, most understand that maintaining such a relationship requires consistent and mutual effort, sacrifice, and investment. Finally, many relationships move through predictable stages (e.g., from initial attraction, to romance and passion, to true intimacy, and finally to commitment) with the expressed goal of solidifying and maintaining the connection while honoring the individuality of each individual in the relationship. Sounds ideal?

What makes addiction an abnormal relationship? First, this relationship is between a person and an object or event (e.g., alcohol, sex, cocaine, food, spending). This kind of relationship involves twisted concepts of respect, love, and trust: People come to love and trust the object or event to meet their needs and push away anyone or anything that interfere with that bond. Similarly, this unilateral relationship consists of efforts to satisfy one’s personal needs to the exclusion of family, friends, and loved ones, while at the same time demanding painful sacrifice from these same relationships. Finally, the abnormal relationship pathologically progresses through the same initial stages found in healthy relationships (attraction and passion) but lacks the sustained intimacy and mutual commitment. Individuals are initially attracted to an object or event because it makes them “feel good,” it helps them forget about life for a while (i.e., numb emotional pain or cancel out boredom), and most importantly, it helps them feel like they’re in control (of their feelings, of reactions to external events, or of others’ reactions). Next, they come to anticipate the next romantic connection with their object or event, they share their object or event with others who are attracted to it, and they begin to form a passion for what the object or event provides for them (such as control, a sensation, escape, or avoidance). Unfortunately for them, since an object or event cannot provide true intimacy, and given that the yearning for intimacy remains, individuals often find themselves using more and more of the object or event in a desperate search for an unobtainable connection and fulfillment. Despair tends to follow as individuals (a) find themselves hooked on a cycle of passion and unfulfilled intimacy and (b) find that any semblance of control has been lost (including loss of control of their own feelings, loss of control [and often a worsening] of external events, and a loss of control over others’ reactions). We have found it helpful to examine this definition with clients (similar to how we’ve done it here) and then encourage them to explore if (and/or how) it helps them to understand addiction.

Here is another lay definition to discuss with clients: Addiction can be defined as An increasing desire for something with a decreasing ability to satisfy that desire. When exploring this definition with clients, you might want to refer to the metaphor of digging a hole at the beach. Clients can be asked if they have ever gotten right up next to the incoming tide and tried to dig a hole in the sand. As anyone who has had this experience can attest, the deeper one digs, and the more one tries to keep the incoming water out of that hole, the more frustrated one becomes: the water just keeps on coming. Clients often recognize how their compulsive attempts at getting high through the use of heroin, gambling, the Internet, or exercise approximates that digging experience: The desire to dig the hole and keep it dry is in direct opposition to the ability to do so.

How about one more? If you like mnemonics, you’ll love the “3 Cs” as they relate to identifying an addiction: An addiction is likely present when someone uses a substance or behavior Compulsively and repetitively, when that use results in negative Consequences, and even with those consequences, the person Cannot stop. These three Cs can be turned into a structured interview (of sorts) where the client can be invited to reflect on (a) his/her use (are there times when he/she sees a pattern of compulsive use?), (b) what he/she has noticed as a result of the use (is it impacting relationships or perhaps his/her mind or body?), and (c) how effective his/her efforts to back off/control the use have been.

Additional client-centered definitions can be derived from the various etiological and treatment theories of addiction. These theories can be explained to clients and their families to assist them in understanding the impact of their addictive disorders. Since we will explore each of these theories in depth in the next chapter, let’s move into a discussion of clinical definitions, as this will shape how we conceptualize, assess, and treat struggling clients with a comprehensive and sequential treatment model.

Clinical Definitions—Can We Agree?

When speaking to clinical professionals (e.g., medical personnel, insurance companies, and other colleagues), a formal definition of addiction is oftentimes most appropriate. These definitions (particularly for how they relate to substance use disorders) emanate from the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-V) (American Psychiatric Association [APA], 2013). “Raised” on earlier versions of the DSM (III and IV), we have been thrilled with the significant changes that occurred related to substance use disorders in the fifth version of the manual. The DSM-V changed the face of addictions counseling when it moved substance use disorders out of a categorical disorder and into a spectrum-based disorder. More specifically, the fifth edition eliminated the diagnoses of Substance Abuse (whereby an individual had to meet a minimum of one criteria out of four) and Substance Dependence (where a minimum of three out of seven different criteria were required) and replaced it with 11 criteria that can be met and classified at various levels of severity. Additional changes found in the fifth edition include the addition of “drug cravings” to the list of criteria and the elimination of “legal related problems” (a prior criterion for Substance Abuse) due in part to its racial/cultural diagnostic inequities. One final important change was the addition of a new section of “behavioral addictions” (which we will discuss further later in this chapter).

We have already seen the positive impacts of these shifts in both our own clinical work as well as those of the counselors we supervise. Perhaps most importantly, the change has resulted in encouraging counselors to more accurately assess the severity of their clients’ substance use disorders. Previously, counselors were often left trying to discern which of the original 11 criteria (four for Abuse and a separate seven for Dependence) their clients met while trying to keep the two very different categories in mind. This became challenging when clients met a couple criteria for Substance Abuse and a couple other criteria for Substance Dependence (but not enough for a diagnosis of Dependence). Counselors were often left with either under-diagnosing their clients (resulting in a diagnosis of Abuse) or forcing the issue by looking for evidence indicating at least one more criteria for the Dependence classification (which resulted in clients being able to receive the services they needed for treatment). Similarly, it eliminated the need for a formal diagnosis of Substance Abuse when only one criteria from that disorder (“legal related problems”) was met. Therefore, if someone is arrested while driving under the influence of alcohol, based on that sole event, they no longer meet criteria for a substance use disorder. Given that racial minorities continue to be charged with crimes (like DUIs) at rates higher than Caucasians, this also resulted in less minorities being diagnosed with substance use disorders. But enough reminiscing about the challenges attributed to older versions of the DSM, let’s get into the diagnostic criteria.

Substance use disorders are defined by the DSM-V (APA, 2013) as a maladaptive use of chemicals that occurs over time and that impacts major life domains and responsibilities. Within a 12-month timeframe (i.e., criteria older than 12 months do not “count”), individuals who exhibit the following criteria can be diagnosed with a substance use disorder (examples are provided for clarification):

• More chemicals are used than was planned or used over a longer time period than was intended.

• Example: Jessinia’s intention is to have no more than one glass of wine at home each night, but more often than not, she finishes the entire bottle.

• Unsuccessful attempts to control, cut back, or stop chemical use.

• Example: Clive recognizes that things are getting out of control and thus tries to go a week without using cocaine: This has not worked over several attempts.

• Exorbitant amounts of time spent in obtaining the chemical, using the chemical, or recovering from the chemical’s effects.

• Example: Ramon’s heroin use involves hours spent waiting on his dealer to show up, followed by a two-day “bender,” resulting in three more days trying to “pick himself up.”

• Drug craving.

• Example: Deborah has been self-medicating with Xanax for two years now: Without it in her system she longs for the next opportunity to use.

• Role failure/avoiding responsibilities (with detrimental consequences) in such areas as home, school, or work.

• Example: Latasha has been vaping marijuana ever since it became legal. Unfortunately, this has impacted her attendance at work, resulting in her being fired recently.

• Continued chemical use even when doing so significantly deteriorates important relationships or impacts social concerns.

• Example: Shawn has been in a committed relationship for three years, but recently his partner has complained about Shawn’s methamphetamine (crystal meth) “frenzy”: Shawn’s partner has threatened to leave the relationship.

• Sacrifice of activities of a social, occupational, or recreational nature that were once important.

• Example: Billye loves to sing ...