Chapter 1
Introduction

Personal Reflections

As we approach addiction counseling, it is important, as clinicians, that we have as clear an understanding as possible of who we are both personally and professionally in relation to addiction. We need to be brave enough to examine our own experiences with addictive tendencies within ourselves and our loved ones as well as our professional experiences with addicts. These experiences color and shape our work with our addicted clients. If we engage in a thorough self-exploration, we can enter encounters with addicts using a clear, balanced approach and avoid being thrown off balance by the intense force of addiction as it has expressed and expresses itself in our client's life.

I also need to comment on the terminology I have chosen to use throughout the text to describe those clients who struggle with addiction. I use the term addicts or addicted clients even though some readers may prefer the terms person with addiction or people with substance use disorders in order to emphasize the “personhood” of the client. I have chosen these terms because, in my experience of addiction counseling, experienced therapists tend to use the terms I have chosen as well as the clients. By no means is the term meant to be disrespectful to the client. For example, in clinical meetings, I always insist that the person's name be used before their disorder is discussed because, as I tell my students, “They were a person before they developed the disorder and their name is important. They are not their disorder.” My hope is that I do not offend the reader with my choice of terminology, but rather, I encourage the reader to choose a term to discuss the addicted client that they believe is most respectful to their population. I believe that what is important, so critical, so necessary, is that we find terminology and an approach that powerfully invites our clients and their loved ones to heal from the destructive force of addiction.

Objectives

1. To learn the main models of addiction counseling.
2. To understand the history of three influences on addiction counseling.
3. To explore how one's own models of addiction and understanding of influences impact the view of the addicted client, the cause of addiction, and treatment approaches.

Current statistics support the concern for alcohol and drug use in America. The 2011 National Survey on Drug Use and Health (Substance Abuse and Mental Health Services Administration [SAMHSA]) found that about 133.4 million Americans (51.8% of the total population over age 12) drank alcohol, with 22.6% (one quarter; 58.3 million people) having a binge drinking experience at least once in the previous month and 6.2% reporting being heavy drinkers (15.9 million). The survey also found that approximately 22.5 million Americans (8.7% of the total population over age 12) had used an illicit drug during the month before being interviewed. Marijuana was the most common illicit drug used. One area of alarming concern is prescription painkiller medication. The number and percentage of persons aged 12 or older, who were current nonmedical users of pain relievers in 2011, was 4.5 million or 1.7%. The Centers for Disease Control and Prevention (2013) reported that in 2010, the amount of prescribed painkiller medication could result in every American being medicated through an entire day for one month; while they were prescribed for medical reasons, they were misused or abused by others. Overdoses of the prescription painkillers (opioid or narcotic) have tripled in the past 20 years in the United States (SAMSHA, 2010, 2011). Their abuse/misuse has doubled in emergency room visits (SAMSHA, 2010) and teens and adults use them to experience a “high” or use them for other nonmedical reasons (SAMSHA, 2011).

These statistics underscore the importance of understanding the dynamics of alcohol and drug abuse and addiction. The high number of individuals using alcohol and drugs in the United States also supports the need for counselors to understand the dynamics of addiction: It is highly likely that a counselor will work with individuals who are abusing alcohol or drugs in any counseling setting. Understanding the dynamics of addiction can help the mental health professional more effectively meet the needs of the client.

Working with the substance-abusing population, however, can be difficult. Mental health workers, both historically and currently, have not always liked working with alcoholics and addicts for at least two reasons: (1) the difficulty in treating them because of factors such as relapses, poor impulse control, emotional reactivity, and/or lying to protect their addiction; and (2) the lack of knowledge (techniques) on how best to treat them.

However, openness to treating addicts grew as information on how to treat addicts emerged and as additional funding for treatment became available. For example, because addicts commonly deny the consequences of their usage to themselves and others (Levinthal, 1996), it became easier for counselors to deal with denial when the technique of intervention was introduced (Fields, 1995).

Counselors also have potential issues with countertransference. Many helping professionals have negative personal as well as professional experiences working with addicted individuals. This may cause them to avoid or hesitate to work with this population. When working with addicts, they may be caught in familiar patterns of enabling or judging the addicted individual and their loved ones based on their own personal or professional experiences. Also, professionals can have concern they are being conned by addicts to enable their addiction and, as a result, may approach the addicted person in a manner that invites anger and manipulation from the client (Compton, 1999).

Changes in public policy also affected the work of counselors. In 1970, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) was established to provide funding for alcoholism treatment and research, and in the 1970s, insurance companies began to reimburse agencies for providing addiction treatment (O'Dwyer, 1993). The Hughes Act (PL 91-616) established the NIAAA, funded states that established alcoholism divisions, and started alcohol treatment programs for federal employees (Fisher & Harrison, 1997). This policy change expanded the field of addiction counseling. As a result, states started to create credentialing and licensing bodies to ensure quality addiction counseling (O'Dwyer, 1993); being a recovering addict no longer meant immediate entry into the addiction counseling field. Instead, addiction professionals needed to document a combination of credentials regarding both counseling experience and training. Up to the present day, different mental health professional groups have increasingly developed certification and licensure processes for addiction counselors. A general approach to certification and licensure is presented in Chapter 14.

This general expansion of the addiction field (effective treatment, research, certification/licensure) now allows for many routes of entry into addiction counseling. A professional may enter the field initially through research, a certification/licensure process, or additionally through a grassroots network experience of their own addiction recovery. As a result of various starting points of interest and involvement, there are numerous disagreements in the field of addictions on applicable models and effective treatment approaches. For example, some addiction experts emphasize the strengths of the disease model of addiction and Alcoholics Anonymous (AA; Gragg, 1991), whereas other experts point out the weaknesses of the disease model and AA (G. A. Marlatt, 1985b). The influences on and models of addiction counseling are explored in the remainder of this chapter.

This chapter is intended to set the tone for the entire book and is divided into two sections. In the first section of this chapter, three addiction counseling influences that have and continue to shape the addiction counseling field are explored. These are the disease model of treatment, addiction research, and managed care. This exploration is meant to expose the reader to the different forces that have shaped and continue to shape the field of addiction counseling.

The second section presents a view of models used in understanding addiction; these models shape the view of the alcoholic, the cause of addiction, and the focus of treatment. The model is like the foundation of the house, the theory (theories) makes up the structure of the house, and the different rooms in the house are the treatment intervention techniques.

Addiction Counseling Influences

Currently, there are at least three main influences in addiction counseling:

1. The traditional addiction counseling disease model approach that asks: Is this approach healing for the addict within the scope of the disease model of addiction?
2. The addiction research approach that presents counselors with the question: Which addiction counseling approaches are supported in research findings?
3. The managed care approach that confronts counselors with the question: What counseling approaches provide the greatest benefit for the least cost?

Each of these influences has an important impact on addiction counseling and because of their different orientations, there may be confusing messages sent to addiction counselors. For example, disease model counselors may advocate use of the term codependency for the...