Addictions Counseling: A Practical and Comprehensive Guide for Counseling People with Addictions

by Diane Doyle Pita

Overview

This wholly revised and updated edition of Addictions Counseling is widely read by professional counselors as well as ministers, teachers, and nurses. Topics include the counselor's role in recovery, treatment approaches, and sample treatment plans.

Product Details

ISBN-13:	9780824527167
Publisher:	PublishDrive
Publication date:	05/01/2004
Sold by:	PUBLISHDRIVE KFT
Format:	eBook
Pages:	192
File size:	466 KB

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Addictions Counseling

A Practical and Comprehensive Guide to Counseling People with Addictions Revised and Updated Edition

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By Dianne Doyle Pita

The Crossroad Publishing Company

Copyright © 2004 Dianne Doyle Pita
All rights reserved.
ISBN: 978-0-8245-2716-7

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CHAPTER 1

THE COUNSELOR'S ROLE IN RECOVERY

Most clinicians and researchers alike believe the counselor-client relationship to be the most important ingredient in effective counseling. Cognitive theorist and practitioner Beck writes, "A collaborative relationship between the therapist and the patient is a vital component of any successful therapy" (Beck et al., 1993). Miller and Rollnick (2002), who developed motivational interviewing, say, "The therapeutic relationship tends to stabilize relatively quickly, and the nature of the client-counselor relationship in early sessions predicts treatment retention and outcome." K. T. Mueser, arguably the best-known clinical researcher in the dual disorder field, states, "The clinician cannot help the patient modify his or her substance use behavior without a therapeutic relationship" (Mueser, Drake, and Noordsy, 1998). Given that the therapeutic alliance is essential to change, we will spend some time examining how a counselor develops this alliance.

In answering the question of how addictions counselors help clients get sober, we begin by asking how the counseling relationship differs from any other helping relationship. Each semester I ask my students to differentiate the various roles in recovery: counselor, sponsor, friend. This task is not easy because most of the students play all three roles, and the boundaries among them blur. For our own survival, we need to recognize the difference between being a friend, a sponsor, and a counselor.

A friendship is a mutual relationship. The word "mutual" implies an equal exchange of self and support. The sponsor-sponsoree and counselor-client relationships are not mutual. Sponsors and, especially, counselors do not ask their clients for help in solving their life problems. The sponsor has learned how not to drink or use drugs and, thus, can share this experience with his sponsoree. In sponsoring, there is no assumption of a level of education, training, professional ethics, or emotional well-being. The counselor, on the other hand, is perceived as possessing all of these qualities, and more.

The counseling relationship is unique. It is initiated and continues because the client feels a need for special help with a problem that she is not able to resolve on her own or through other relationships. The counseling relationship is structured in time and space. The relationship does not extend beyond the professional relationship or beyond the four walls of the office. The relationship is limited by time. The client typically sees the counselor once a week and does not have unlimited access to her through phone calls or social visits. The relationship is, however, closer and deeper than ordinary social friendships. Professional ethics and laws of confidentiality apply to this relationship.

Perhaps most important is that the counselor is there solely for the good of the client. The counselor's purpose for that hour-long session is to focus on the client and help the client get better. The counselor is being paid to do that; the client has no obligation, no responsibility for the emotional well -being of the counselor. Because the client does not owe the counselor anything (other than the fee), the client trusts that she has an objective listener. The counselor has no ulterior motive. Often, this is the only relationship the client has in which she does not place the other person's needs before her own. In the process of placing herself first and focusing on her own feelings and needs, the client gains a different perspective on herself in relation to another.

Counselor Qualities

There is surprisingly little dissension in the counseling field in defining the necessary counselor attributes. Even where two counseling approaches are diametrically opposed, they tend to agree on the qualities required of the counselor. There may be disagreement on whether the qualities are "necessary and sufficient" for change or whether they are necessary but not sufficient for change. The qualities themselves are, however, basically the same whether we are asking a behaviorist, a psychoanalyst, or a cognitive therapist.

Carl Rogers, who developed self theory and the client-centered approach, has contributed a great deal to our knowledge of what he calls the "necessary and sufficient" conditions for therapeutic personality change. He points out that significant change does not occur except in a relationship. The necessary and sufficient conditions include psychological contact, counselor congruence, counselor empathic understanding, and counselor unconditional positive regard. Congruence refers to the counselor's being genuine or real. Not only does the counselor mean what she says but her feelings also match what she is saying. Empathy involves seeing things through the client's eyes and being able to communicate this experience to the client so that the client knows the counselor understands her. A positive, accepting attitude on the part of the counselor means that she cares about the client as a person with potential. The counselor respects the client as an individual and is nonjudgmental.

One of the most valuable aspects of Rogers's work is that his theory has generated a great deal of research. Research findings support what we would expect to be true: an individual who can communicate warmth, genuineness, and accurate empathy is more effective in helping other people (Truax and Carkhuff, 1967). Based on his research, Carkhuff extended Rogers's theory into an eclectic approach to counseling. The term "eclectic" means an approach that is not tied to a single theory but rather combines selected aspects of various theories. In addition to the core conditions of empathy, positive regard, and genuineness, Carkhuff added concreteness, immediacy, and confrontation. Concreteness involves focusing the client's attention on specific behaviors as they are occurring in the relationship. Immediacy involves the counselor's communicating to the client what the counselor believes the client's behavior means (interpretation). Confrontation means presenting the client with her own behavior by pointing out a discrepancy in that behavior.

These counselor qualities were identified long ago but hold true today. Counselor qualities such as empathy continue to be shown through research to be essential for change. Empathy involves being able to get in the shoes of the client, see things as she sees them, and communicate that understanding to the client. Empathy is not sympathy, which is feeling sorry for someone. Empathy is not identification, which is having in common the past experience. For instance, identification may occur when both the client and the counselor are heroin addicts now in recovery. While having this shared experience may initially facilitate alliance, it may be more difficult for the counselor to maintain objectivity, to not identify with the client. If the counselor identifies with the client rather than demonstrating empathy, she may find herself stuck in the shoes of the client and unable to help either the client or herself. With regard to the expression of empathy, Miller and Rollnick (2002) write, "In fact, a recent personal history of the same problem area (e.g., alcoholism) may compromise a counselor's ability to provide critical conditions of change because of overidentification." The counselor does not impose his own material in expressing empathy. These authors review recent research that shows empathy can determine the clients' response to treatment. For instance, in one study (Miller et al., 1993), they found that drinking outcomes could be predicted from the degree of empathy shown by counselors during treatment. In other words, the more empathic the counselor, the more likely the client was to abstain from alcohol. In contrast, confrontational counseling was associated with a high dropout rate and poor outcomes. The more the counselor confronted the client during treatment, the more the client drank. For counselors still dependent on a "confrontation-of-denial" approach, these findings offer more reasons to develop the technique of empathy.

In The Helping Interview (1974), Alfred Benjamin provides added insight into this concept of unconditional positive regard: "We can best help him through behavior that demonstrates that we consider him responsible for himself, his actions, thoughts, and feelings, and that we believe in his capacity to use his own resources increasingly." No matter what the approach, all theorists stress the need for the client to feel that the counselor is concerned and able to help.

The Role of the Counselor in the Counseling Process

Part of our role as helpers, then, involves establishing a trusting and open relationship with the client. Whereas counselor qualities are pretty much the same across approaches, the role of the counselor in the counseling process is very different. The psychoanalysts, and ego -analysts, the rational therapists (rational-emotive therapists such as Ellis, reality therapists such as Glasser), and the learning theorists and behavioral counselors believe that the counselor is some kind of expert to whom the client has come with a problem that she cannot resolve alone. This assumption leads to the belief that the counselor must take a more active or authoritative role in the counseling relationship. They see the counselor as being responsible for making a diagnosis of the problem and for presenting a treatment plan.

At the other end of the continuum of counseling approaches, Rogerians, Gestaltists, and Adlerians argue that because of people's inherent growth tendency or tendency toward self-actualization, the client has the capacity and the motivation to solve his own problem if provided with an accepting positive counseling relationship. Rogers, in advocating his client-centered approach, stresses that the counselor's presence or behavior in the counseling relationship does not directly influence the client's behavior. In the client-centered approach, it is considered very important that the client set the goals. Thus, the role of the counselor is to provide the conditions (e.g., unconditional positive regard); the client will then change on his own within those conditions. Rogers believes that diagnosing the problem and setting treatment goals create dependence needs in the client.

Rogers with his client-centered approach and Ellis with his rational-emotive therapy obviously disagree on the role of the counselor in the relationship. As Ellis states, "The rational therapist does not delude himself that these relationship-building and expressive-emotive methods are likely to really get to the core of the client's illogical thinking" (Ellis, 1962). Relationship techniques are viewed simply as preliminary techniques and, "the rational therapist goes beyond the point to make a forthright, unequivocal attack on the client's general and specific irrational ideas and to try to induce him to adapt more rational ones in their place" (Ellis, 1972). Ellis places responsibility on the client; he views the client as having the capacity to change.

The Counselor's Role in Recovery Counseling

Interestingly, a major point of departure between these approaches is the question of dependence. Ellis, through a didactic or teaching approach, clearly defined treatment objectives, and homework, puts the responsibility on the client. Rogers, on the other hand, believes that client independence and responsibility can be achieved only by setting up the proper external conditions (empathy, positive regard) and then waiting for the client to change. The counseling approach of choice in addictions or recovery counseling would include both components as necessary and sufficient conditions. Recovery from addiction requires counselor qualities and the establishment of a therapeutic relationship as well as clear education, instruction, and a plan of action.

If a client suffering from an addiction comes to us and asks for our expert help in solving his life problems, just on ethical grounds alone, it seems, we need to provide him with an accurate assessment and treatment plan. As addictions counselors, we believe that while the individual is actively engaged in his chemical addiction, he has very little freedom of choice; that is what concepts such as "denial," "loss of control," and "disease" are about. If a cocaine addict comes to us for help and we do not confront him on his addiction problem, it doesn't matter how accepting and genuine we are; he is probably not going to conclude on his own that he must abstain from all drugs.

A major difference in treating the addictions is thus the necessary condition of an active, direct, didactic approach with a clear plan of action. This approach is necessary in the early stages of counseling: assessing the problem, helping the client see that the chemical is the problem, and helping him to stop using the substance. The approaches of Ellis and Rogers, although at the extremes, are not mutually exclusive. We need to understand that confrontation is a part of being genuine and honest. Understanding the complementarity of seemingly opposing concepts is the key to effective addictions treatment. The complementarity of concepts such as "tough love," "responsibility and freedom," and "gaining control by letting go," are basic to understanding the recovery process. We give the clients the tools of sobriety and then we let go, encouraging them to use the tools in their own way.

As addictions counselors, we must be very clear in understanding the difference between accepting a person and accepting a behavior. This is essential to addictions counseling to ensure not only that we accept the client and treat the client effectively but also that we can teach the client to accept himself. We do not accept or pretend to accept the addict's bad (hurtful, self-destructive) behavior. The person, however, we accept as a human being worthy of help. We care about and respect the addicted individual enough to trust that, with psychoeducation and challenges to his unhealthy belief systems within the context of a trusting therapeutic relationship, he can become responsible for making his life what it can be. Later on in recovery, as the client moves out of denial and into a more self-exploratory phase, the conditions outlined by Carkhuff in his eclectic approach, or any other recognized approach for that matter, may prove necessary and sufficient in facilitating change.

In addition to bringing ourselves as human beings to the counseling relationship, what else is necessary for change? We must bring our expertise in treating addictions (a knowledge base and experience), we must bring our professional ethics, and we must bring our knowledge and skills in the techniques of counseling. The great distance between knowing how to get a person sober and getting the person to "hear" what we know when we speak is closed by relationship attitudes and skills.

CHAPTER 2

CHOOSING A MODEL OF ADDICTION

Historically, the scientific community and laypersons have defined alcohol and drug-related problems in their own way, depending on the political and social times and their own personal feelings. How we conceptualize the disease influences how the disease is treated. When society viewed the alcoholic as morally weak, he was ostracized to skid row. Later, the alcoholic was thought to have a physical sickness, a disease, and was treated by physicians in a hospital setting. Today, alcohol and drug addiction is generally defined as a disease by the people treating it; however, there is reluctance on the part of the public and medical professions to recognize it as a chronic rather than acute disease. The public and professionals alike often think that people should be treated once for this disease, and then they should be able to maintain abstinence on their own.

(Continues...)

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Excerpted from Addictions Counseling by Dianne Doyle Pita. Copyright © 2004 Dianne Doyle Pita. Excerpted by permission of The Crossroad Publishing Company.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Table of Contents

Contents

Acknowledgments,
Introduction,
1. The Counselor's Role in Recovery,
2. Choosing a Model of Addiction,
3. Phases and Categories of Addiction,
4. Cognitive Therapy,
5. Ethics for Professionals Working with Addicts,
6. Twelve Step Principles and Cognitive Therapy,
7. What's New in Treatment? A Cognitive-Behavioral-Twelve Step Approach to Alcohol and Other Drugs,
8. Integration of Approaches / Adding Motivational Interviewing to the Cognitive-Behavioral-Twelve Step Mix,
9. What's New in Treatment Populations? Dual Diagnosis,
10. Special Topics in Addiction / Nicotine, Medication, Family, Women, and Adolescents,
11. Recovery Counseling Overview,
12. Stage I / Initiating Treatment,
13. Stage II / Stopping the Compulsion,
14. Stage III / Working and Playing Sober,
15. Stages IV and V / Identity and Intimacy in Recovery,
16. Stages VI and VII / Identity and Intimacy Development,
Conclusion / What Is Recovery?,
Appendix A / The Twelve Steps of Alcoholics Anonymous,
Appendix B / Sample Treatment Plans,
Appendix C / Return-to-Work Agreement,
Appendix D / Intimacy Maturity Interview,
References and Bibliography,
About the Author,