Theory and Practice of Addiction Counseling

Pamela S. Lassiter, John R. Culbreth

• Publisher: SAGE Publications, Inc
• Year: 2017
• ISBN:
  9781506317311
• Edition: 1
• Topic: Education
• Subtopic: Education Counseling

This one-of-a-kind text brings together contemporary theories of addiction and helps readers connect those theories to practice using a common multicultural case study. Theories covered include motivational interviewing, moral theory, developmental theory, cognitive behavioral theories, attachment theory, and sociological theory. Each chapter focuses on a single theory, describing its basic tenets, philosophical underpinnings, key concepts, and strengths and weaknesses. Each chapter also shows how practitioners using the theory would respond to a common case study, giving readers the opportunity to compare how the different theoretical approaches are applied to client situations. A final chapter discusses approaches to relapse prevention.

1 From Treatment Lore to Theory Application: An Introduction to Addiction Theory and Practice

John R. Culbreth

Pamela S. Lassiter

This text explores multiple theoretical approaches to both the epistemology of addiction and its treatment. It is important for the reader to understand our perspectives as editors because who we are and what we believe ultimately defines the lens through which we have edited this book. Both editors subscribe to a biopsychosocial and spiritual theoretical perspective regarding the causes and maintenance of addiction. We believe that there are crucial biological, psychological, sociological, and spiritual factors at play in the creation of addiction and in the maintenance of that addiction once it has begun. We also both believe that the treatment of addiction must necessarily include all of those aspects in order to adequately address the disease of addiction.

Additionally, we base our work on several underlying assumptions about addiction counseling. These include the following:

• Theories or models are underlying guides in clinical practice that include our beliefs about what causes problems in our lives and about how and why people change in response to those problems. In counseling, our theories reflect who we are as much as they reflect our beliefs about change. In other words, our adopted counseling theories are selected based on our own developmental process and our resulting worldview.
• We assume that counselors should be engaged in an ongoing, reflective practice concerning their biases about addiction and addicted people. Most of us have been impacted by addiction in some way. Personally speaking, after 30-plus years of practice and a strong belief that addiction is a disease that literally hijacks the person’s brain, it is still difficult not to fall into moral model beliefs when a young college student is killed by a drunk driver with eight previous convictions of driving while impaired. We have to understand those judgements, accept that we will always have them (just as racism and sexism will always reside within us), and choose consciously not to act out of that place when we provide treatment.
• There is a strong connection between what a counselor believes about the causes and maintenance of addiction and how that counselor will go about treating the addicted client. Likewise, we assume that the chosen theory of counseling determines the type of treatment approach a counselor will choose to take with a client. For example, if a counselor believes family distress is a major contributing factor to a client’s addiction, then the counselor may choose family therapy or a systemic approach as a primary treatment modality. If psychological issues are seen as the underlying cause of the addiction, remedies such as stress reduction techniques or anxiety or depression medication may be sought. Regardless of the counseling theory applied to work with addicted clients, the onus is on the counselor to explore his or her own biases about addiction, addicted people, and proper treatment.
• We also assume that best practices in addiction counseling are supported by a sound theoretical approach that is evidence-based in terms of effectiveness. Whereas not all aspects of theory are “proven” to be effective, our general approaches to treatment ought to be based on empirical support for those practices.

Treatment Lore

Training to be a substance abuse counselor during the 1980s, when we came through our own counselor training programs, was quite different from addiction counseling training today. And yet there are many aspects of that early training that remain in today’s addiction counseling curriculum. Much of this can be called treatment lore. This lore for working with addicted clients has its history within the development of the field through the 20th century. It is connected to Alcoholics Anonymous and the disease model in many ways. The concepts of treatment lore have been handed down in a way similar to an oral history. With this in mind, please note that we are not taking credit for these concepts and ideas. This is merely a presentation of accumulated lore that we have learned through the years by way of in-service training, our own clinical supervision as counselors, treatment program curricula, and psychoeducational materials used by counselors with clients. And our use of the word lore does not suggest that these concepts are untrue. They are simply a part of the accepted culture of addiction counseling, impacting the ways in which addiction counselors perceive and work with clients.

The use of treatment lore continues today, although we believe that in the classroom there has been a significant shift in focus toward empirically based approaches and theories that have solid foundations in the larger counseling and psychotherapy fields. Where treatment lore persists is in the multitude of professional development trainings, workshops, addiction counseling training institutes, and the addiction treatment agencies. Graduates of counseling programs obtain positions in treatment programs that work from this treatment lore approach. Granted, more and more programs are being required to demonstrate that treatment provided is theoretically and empirically grounded. However, this requirement is not universal, resulting in many treatment center and program addiction counselors mashing together ideas, beliefs, and personal experiences into how they work with clients on a day-to-day basis.

Although we do not advocate using treatment lore as the foundation for how counselors work with addicted clients, we believe it is important to present some of these concepts for two reasons. First, it is important that new counseling professionals entering the field understand some of the culture of their intended work environments. Many of these concepts are held to by working addiction counselors at almost a visceral level. We believe this is due to some of these counselors having either come through their own recovery process or having a close family member in recovery. The result is that these beliefs are directly related to the fact that this professional is still alive and breathing today. Personally speaking, were it not for some or all of these ideas, some of our own family members would be dead due to their addiction. This belief makes for a “true believer” in those who have gone through this experience. And sometimes a true believer can be less open to alternative ways to conceptualize addiction and work with addicted clients.

The second reason for presenting this information is that much of it makes sense and can accurately describe some of the experiences and issues that addicted clients have to address in their process of recovery. This piece of lore helps counseling professionals understand these issues as well, allowing for a better understanding of their client experiences. If some of these ideas are accurate, which we believe is the case, then addiction counselors will be able to teach these ideas to clients and help them progress in their recovery.

In looking at what we consider to be common treatment lore, there are several groups of concepts, including a definition of addiction, descriptors of the illness and how it manifests in clients, and things to consider when working with an addicted client. We briefly discuss these concepts and provide examples of how they are used.

A common issue when beginning work with addicted clients is a resistance to the term alcoholic or drug addict. Both terms carry many negative connotations and negative stereotypical views. Often clients openly and defiantly state that they are neither one of these types. Our response is to agree with the client, stating that it is not our job to make that determination; it is the client’s right to decide what levels of difficulty he or she has with chemical use. We provide a common definition in individual, group, or psychoeducational counseling, stating that addiction is the compulsive use of a mood-altering substance or behavior, which continues even in the face of adverse consequences. One of the best known advocates of this definition has been Father Martin, who has taught this concept in his well renowned video Chalk Talks (Kelly Productions, 1972). An important corollary to this definition is that it is important for counselors and clients both to understand that the chemical itself (or behavior in a process addiction) is not the primary problem. Rather, it is the behaviors, cognitions, and emotions surrounding the use and abuse of the chemical (or process) that are important. In other words, it is not the alcohol that is important in alcoholism; it is the “ism” that has to be addressed. Alcoholism, cocainism, workaholism, hypersexism, gamblingism, and perfectionism are all about the “ism.” Each one of these “isms” is merely a different way for a person to alter his or her mood. Put another way, “A drug is a drug is a drug.”

Another treatment lore relates to how the nature of addiction is explained to clients so that they can understand what they are experiencing as they move through recovery. This description is commonly referred to as 3 Ps and a T. This name stands for addiction being a primary illness that is progressive and persistent and if left unchecked is terminal. A primary illness is one that requires treatment before any other issues or concerns are addressed. In addiction counseling, this is related to clients who may focus on other psychological or emotional problems, bypassing dealing with their addiction problem, thus never addressing this issue. As counseling on the other problem progresses, often a client may begin self-medicating the pain that arises with chemicals or processes, rather than developing more appropriate and healthy coping strategies. Progress is limited at best and often very temporary. Eventually the counselor may uncover what is actually happening with the client and try to address the chemical use, with varying levels of success. Thus, a successful outcome for the client is blocked due to the primary illness overshadowing any efforts by the client or counselor to make positive changes.

Addiction as a progressive problem refers to the series of negative consequences associated with compulsive unchecked use. These consequences follow a sequence from mild to moderate to severe in nature. Examples of mild consequences include an increase in tolerance to alcohol, onset of memory blackouts, and an inability to stop drinking even once others have done so. Moderate consequences include failed efforts to control intake amount or quit altogether; negative impact on work, finances, and family and friends; and the development of tremors. Severe consequences include physical and moral deterioration, lengthy episodes of intoxication, and a decrease in tolerance to alcohol, also known as reverse tolerance. Each of these levels of severity coincide with viewing addiction through a three-stage model of progression. Jellinek (1960) created a diagram called the Jellinek Curve that displays how clients progress downward through the early, middle, and late stages of addiction. The opposite side of the curve represents steps and progress markers for clients who are working up toward recovery. The two sides create the curve, or U shape, of the progression of addiction and the progression through recovery.

The concept of persistence explains the fact that this problem cannot be ignored with the hope that it will eventually go away or resolve itself. Addiction must be addressed directly, head-on, through active participation in a treatment process. Clients must understand that their work toward recovery cannot become complacent. The idea of persistence is especially difficult for parents to accept, especially when they say to a counselor that the using behavior of a child is just a phase and that the child will grow out of it. Many times this can happen. But more often, once someone’s use and abuse of chemicals comes to the attention of professionals, it is well beyond the experimentation stage or phase. At this point, the addiction is present and persistent and will not go away on its own.

The final descriptor, T, refers to addiction being a terminal condition. If it is left unchecked, due to its persistent nature and the progression through increasingly severe consequences, then the final outcome is likely to be death. Death may come about in a variety of ways. It can be over the course of time through the physical deterioration of the body (although time here is relative based on the quantity and frequency of individual use). Or death can be a result of participating in risky behaviors due to impaired thinking, such as a traffic fatality. Many addicted people struggle with depression and so are at significant risk of chemically induced suicidal ideation and behaviors, sometimes resulting in a successful suicide.

A second group of descriptors about addicted clients are the three Ds of addiction: denial, delusion, and dishonesty. Denial is probably the most commonly known of these three, although the other two appear obvious once considered by the addiction counseling student. As clients progress through addiction, they begin to deny the impact of their behaviors and subsequent consequences. Often they will look to place the blame for any negative consequences on any number of other areas rather than their use and abuse of chemicals. It is common to hear clients refer to getting arrested for driving while impaired as merely having to fill a law enforcement officer’s quota of citations. Disregard the fact that the client was actually driving while impaired. Other clients will attribute their abuse of chemicals to negative or dysfunctional relationships. All of this is denial.

As the denial increases with the progression of addiction, clients will begin to develop patterns of impaired thinking, or delusions, surrounding their chemical abuse. This may include unreasonable resentments toward family and friends. As the chemical or process obsession grows, these can lead to delusional thinking. Often, this delusional thinking supports a delusional belief of persecution by people in the lives of clients.

The third characteristic, dishonesty, is connected to the first two, in that clients will often go to great lengths to avoid the truth of their addiction. This includes the dishonesty toward the self through denial and delusional thinking, as well as dishonesty in everyday interactions with the people they interact with. A system of lies is created that insulates clients from the negative consequences of their behavior. Many people close to the addicted person either openly support this dishonesty through enabling behavior or covertly support the dishonesty by creating their own “reasons” for the abusive behavior and associated consequences. Both of these compensation approaches by friends and family members share a common characteristic of not directly and honestly confronting the inappropriate abuse behavior, thus resulting in shielding, either intentionally or unintentionally, the ...