Substance Abuse Counseling Theories Substance

Substance Abuse

Counseling Theories

Substance abuse: Reality therapy and other alternative therapeutic strategies

Substance abuse: Overview

"This is your brain. This is your brain on drugs." "Don't drink and drive." The slogans are familiar, yet these Madison Avenue buzzwords have not eradicated the problem of substance abuse in American society -- or the problem of substance abuse around the world. Drug abuse is defined as using substances in a way to "produce some form of intoxication that alters judgment, perception, attention, or physical control" over an individual's faculties (Substance abuse, 2009, E-medicine). When an individual has become addicted, he or she will experience withdrawal symptoms upon the removal of the substance. "Withdrawal can range from mild anxiety to seizures and hallucinations. Drug overdose may also cause death. Nearly all these drugs also can produce a phenomenon known as tolerance where you must use a larger amount of the drug to produce the same level of intoxication" than when previously exposed (Substance abuse, 2009, E-medicine).

Quite often, denial or a feeling of being 'in control' is part of the illness of addiction, even when other people around the abuser see that the addict's life is unraveling. Although people abuse drugs for many reasons, substance abusers often have experienced little control over other facets of daily life. The addiction bolsters their self-esteem and gives them a seemingly controllable aspect to their existence (the taking of the drug), as well as a built-in (albeit negative) social structure of friends and a habit to fill time that otherwise might be felt suffering depression or emptiness. Not all drug addicts are depressed, or suffer other psychological conditions (environmental and biological predispositions also play a role) but it is not uncommon for drug addicts to exhibit co-morbidity, or other psychological abnormalities, such as mood and personality disorders. These disorders may be the cause of the addiction, or conversely encourage the addiction to take hold.

Substance abuse can be a form of self-medication: using the drug temporarily alleviates the sufferer's anxiety, particularly social anxiety. For example, alcohol temporarily depresses the user's inhibitions, but does not treat the fundamental causes of the anxiety, so the user must return to the drug again and again to feel 'normal' in a social environment. Also, certain social environments, such as college or even national cultures (Russia and Ireland) that normalize heavy drinking can encourage substance abuse. Other subcultures may even normalize 'hard' drugs, such as heroin or crack cocaine. Biological, social, and cultural facilitators all conspire to make escaping the grip of addiction extremely difficult.

Denial may be facilitated by the addict's friends and family. Even within professional cultures, heavy drinking may be normalized, particularly if the individual seems to be able to keep work and family commitments despite a heavy drinking 'schedule.' "The functional alcoholic consumes as much alcohol as any 'full-blown' alcoholic, they just don't exhibit the outward symptoms of intoxication" or the symptoms of intoxication may have become so habitual they go unnoticed by friends and family (Buddy 2009). Chronic addicts may develop a functional tolerance to their substance of choice, "to the point that it takes more for them to feel the effects, which may create the impression that they do not have a 'problem' (Buddy 2009). However, this does not mean that the addict is unimpaired, in fact the need to drink increasingly larger amounts to get high or even feel normal means that the "slow build-up of alcohol tolerance" has taken hold and the functional alcoholic is likely "drinking at dangerous levels that can result in alcohol-related organ damage, cognitive impairment and alcohol dependence" (Buddy 2009). Heavy drinking is defined as five or more drinks per day but if the addict sees 'everyone' drinking that much around him, or abusing drugs, the behavior seems less aberrant and thus less unhealthy (Blakeley & Hutchinson 2009).

Of course the functional alcoholic or substance abuser often becomes the stereotypical 'nonfunctional' addict -- it could be said that functional addicts are merely addicts in a less advanced stage of the addictive process, although some substances may tend to have a more hasty progression (such as crystal 'meth' or 'crack' cocaine). Regardless, the ultimate costs to society and the individual are high -- lost productivity, deaths and injuries due to substance-abuse related accidents, broken homes, traumatized children, and increased rates of sexual crimes because of the loss of inhibition on the part of the perpetrator or the ability of the victim to defend him or herself. "Alcohol consumption is the fourth leading cause of death in the United States; annually, over 100,000 deaths, both accidental and non-accidental, are related to alcohol consumption, or 5% of all deaths. Alcohol consumption is associated with a myriad of health consequences from cirrhosis of the liver to diabetes. Abuse of alcohol is a particular concern for pregnant women and the developing fetus due to the risk of birth defects" (Blakeley & Hutchinson 2009).

Traditional approaches to treatment

Alcoholism and substance abuse have traditionally been treated with medical support designed to minimize the effects of withdrawal, including methadone treatment for heroin addicts, or other drug-based or physiological methods designed to mitigate the cravings, tremors, or other symptoms of addiction in general. Follow-up with support groups such as Alcoholics Anonymous or Narcotics Anonymous is also often prescribed. Yet these groups have come under increasing criticism for their rigid adherence to a particular one-size fits all formula. There is a controversy as to whether the 12-step approach is really effective, or more effective than other types of treatments. "Alcoholics Anonymous (AA), the increasingly popular mutual-help program for alcoholics, is often criticized for being just another substitute addiction, emphasizing powerlessness to already disenfranchised groups" such as women and minorities who might have very little power over other aspects of their lives (Davis & Jansen 1998). It is argued that a sense of helplessness is exactly what frequently drives members of these population groups to become addicted in the first place. AA and NA are also problematic for non-believers, given both organizations' emphasis on a higher power. AA and NA have both been accused being a religion or cult and "adhering to a medical model of disease instead of a strengths perspective, and other such areas of concern to social workers" (Davis & Jansen 1998)

When compared with other programs, including "cognitive-behavioral therapy, which encourages the conscious identification of high-risk situations for alcohol use; motivational enhancement therapy, based on principles of social and cognitive psychology; and relapse prevention therapy, a variation on the cognitive-behavioral approach," and "other spiritual and non-spiritual 12-step programs," a survey of eight trials involving 3,417 men and women ages 18 and older " showed that 12-step interventions were not "any more -- or any less -- successful in increasing the number of people who stayed in treatment or reducing the number who relapsed after being sober," and one-fifth of the subjects in the study remained sober without any formal treatment at all (Bakalar 2009). Although some individuals find AA and NA helpful, this suggests that other treatment strategies should not be ignored, and AA and NA might not be 'the only way' as is sometimes suggested.

New approaches

Reality therapy is a methodology of therapeutic practice that is highly future-focused, and in contrast to AA, focuses on patient empowerment. "Its fundamental idea is that no matter what has happened in the past, our future is ours and success is based on the behaviors we choose" (Reality therapy, 2008, International Journal of Reality Therapy). For some substance abusers, who often must make a total break with the past to recover from their addiction, reality therapy may prove uniquely beneficial, even if the addict has not found other therapeutic techniques to be helpful in managing their cravings before. Often a variety of approaches must be tried: addiction is a famously stubborn psychological illness to heal, but reality therapy can provide a potent and persuasive tool to deal with some of the underlying problems experienced by many addicts, such as trusting others and feeling secure without the crutch of drugs and alcohol.

The reasons for relapse can be multifaceted, and partially due to the addict's personality and the nature of addiction. Yet in the 12-step and spiritually based approaches, many argue that there is insufficient acknowledgement of the realities of the situation of the addict, outside of the physical addiction itself. The social forces propelling the addict back to his or her habit can be just as powerful as the physical pull of the addiction itself, and reality therapy strives to give patients to overcome the social and physical pull of the drug and to form positive social connections.

In contrast to AA, there is a new stress upon treating the problems of the individual holistically, rather than focusing on the addiction alone. For example, women who are addicted to drugs and/or alcohol have a specific profile often unacknowledged by generic treatment models such as AA. In one study "74% of the addicted women reported sexual abuse, 52% reported physical abuse, and 72% reported emotional abuse" (Covington 2008). It has been argued that despite this fact, because substance abuse treatment has been developed by men, for men, it emerged "as a single-focused intervention based on the needs of addicted men." (Covington 2008). Without empowering substance abusers whose lives have become severely impaired in terms of basic life functioning, treating the abuse or disability as a purely biological function will have little effect, and only address the physical withdrawal symptoms, and surrendering to the addiction may not address the need to seek out new, positive social relationships and to actively construct an environment that does not facilitate the addiction.

Even addicts with jobs who are minimally socially functional may have social structures revolving around their addiction. In the case of many women in particular, the life pattern of being involved with an abusive partner, which may have driven the women to abuse drugs in the first place, becomes a cycle of addiction and dependence upon an abusive person for self-esteem, access to drugs, and economic support. For patients who are substance abusers in economically deprived area where drug addiction is normalized, removing the patient from the subculture and the environment, and supplementing treatment with vocational support may be more important as the personally-focused, small, anonymous setting of AA or NA. The individual may also need more outside assistance than is typically provided by the person-focused AA approach.

Non 12-step advocates believe treatment must be holistic and consistent, and counselors who focus only on the addiction and cannot assume other issues will "resolve themselves" (Covington 2008). The attitude that other problems may 'resolve themselves' is only appropriate if the other problems have their root cause n the addiction. But a woman married to an abuser, for whom enduring abuse is a common life pattern, may need additional social support for education, vocational assistance, and a way to reconfigure her life and self-esteem, even if she is committed to recovery. "Treatment for women's addictions is apt to be ineffective unless it acknowledges the realities of women's lives, which include the high prevalence of violence and other types of abuse. A history of being abused increases the likelihood that a woman will abuse alcohol and other drugs" (Covington 2008). Relapse is likely if a viable alternative life is not supported -- the individual's life must not just be drug-free, but the cultural conditions that facilitate drug use must be altered. This requires empowering the patient, rather than stressing the patient's powerlessness. But it also takes some of the burden off of the patient that relapses are his or her fault, and strives to create a better environment to support his or her needs.

Rather than the searing self-criticism of AA and traditional 12-step programs, reality therapy focuses upon creating a trusting environment for the client: "Since unsatisfactory or non-existent connections with people we need are the source of almost all human problems, the goal of reality therapy is to help people reconnect. This reconnection almost always starts with the counselor/teacher first connecting with the individual, and then using this connection as a model for how the disconnected person can begin to connect with the people he or she needs" (Reality therapy, 2008, International Journal of Reality Therapy). For substance abusers, the disconnection is often profound, and results in the abuser being frozen in a subculture and lifestyle that revolves around drugs. Freeing the addict from this subculture is essential, but little benefit will result from pressuring the individual to 'just quit.' Reality therapy stresses the counselor should "remain non-judgmental and non-coercive, but encourage people to judge all they are doing by the Choice Theory axiom: Is what I am doing getting me closer to the people I need? If the choice of behaviors is not getting people closer, then the counselor works to help them find new behaviors that lead to a better connection" (Reality therapy, 2008, International Journal of Reality Therapy).

This stress upon choice is counter-intuitive to many therapists trained in the 12-step model, which stresses giving over control to a higher power, and the addict's powerlessness over his or her addiction. It also runs counter to some other proposed models such as the "Women's Integrated Treatment (WIT) model. This model is based on three foundational theories: relational-cultural theory, addiction theory, and trauma theory. It also recommends gender-responsive, trauma-informed curricula to use for women's and girls' treatment services" (Covington 2008). Attempts to treat the addict by focusing on the past run counter to reality therapy's core schema of beliefs. Instead the reality therapist keeps the "focus on the present and avoid discussing the past because all human problems are caused by unsatisfying present relationships" (Reality therapy, 2008, International Journal of Reality Therapy).