Chapter 2 - Overview
Individual drug counseling focuses on the symptoms of drug addiction and related areas of impaired functioning and the content and structure of the patient's ongoing recovery program. This model of counseling is time limited and emphasizes behavioral change. It gives the patient coping strategies and tools for recovery and promotes 12-step ideology and participation. The primary goal of addiction counseling is to assist the addict in achieving and maintaining abstinence from addictive chemicals and behaviors. The secondary goal is to help the addict recover from the damage the addiction has caused in his or her life.
Addiction counseling works by first helping the patient recognize the existence of a problem and the associated irrational thinking. Next, the patient is encouraged to achieve and maintain abstinence and then to develop the necessary psychosocial skills and spiritual development to continue in recovery as a lifelong process.
Within this counseling model, the patient is the effective agent of change. It is the patient who must take responsibility for working on and succeeding with a program of recovery. Although recovery is ultimately the patient's responsibility, the patient is encouraged to get a great deal of support from others, including counselors and other treatment staff, one's sponsor, and drug-free or recovering peers and family members.
Overall, drug use is thought to be a multidetermined, maladaptive way of coping with life's problems. It sometimes becomes compulsive and leads to a progressive deterioration in one's life circumstances. Compulsive drug abuse is addiction, which is defined as a disease. It damages the addict physically, mentally, and spiritually.
Comparison of Addiction Counseling and Psychotherapy
In the research protocol for which IDC was developed originally, it was extremely important to clarify the boundary between addiction counseling and psychotherapy. Addiction counseling and psychotherapy were compared to determine if one was more effective than the other for the treatment of cocaine addiction. In clinical practice, however, the boundary between addiction counseling and psychotherapy often is blurred. To aid understanding of the contrast between addiction counseling and psychotherapy, the elements of addiction counseling that may differ from psychotherapy are discussed here.
Addiction counseling involves setting and encouraging the patient to work toward predominantly short-term goals. Although the goal of continued abstinence supported by a change in lifestyle is not short-term, the 12-step adage of "one day at a time" creates a short-term way of working toward lifestyle change.
The goals of IDC are always directly related to recovery from addiction. For example, an appropriate goal in addiction counseling might be for the patient to terminate an abusive relationship that enabled the patient's drug use, but it would not be an appropriate treatment goal for the patient to work through issues stemming from his or her early abusive relationship with a parent. Another appropriate goal of addiction counseling would be to recognize the impact of one's dysphoric feelings on one's drug use and to develop a strategy for responding in a new way that does not involve drug use. However, it would not be appropriate to do a cognitive analysis of the thoughts that underlie the dysphoria. The addiction counselor tries to provide the patient with concrete, behavioral options to facilitate recovery. Such options include avoiding those things that trigger drug use, attending self-help groups, and leaving or changing situations or relationships that contribute to the addiction.
Finally, addiction counseling focuses primarily on the present rather than the past. The counselor might become familiar with some of the significant historical data but would not direct interventions aimed at understanding the effects of past events, except perhaps those events that are related to the addiction.
Below is a comparison of addiction counseling with a typical model of psychotherapy, which would include psychodynamic approaches and cognitive therapy, as well as other approaches. However, not all models of psychotherapy are consistent with this simplified model.
Goals directly related to addiction
Focus on the present
Short- and long-term goals
Cognitive, emotional, and behavioral goals
Goals related to all areas of recovery
Focus on the past and present
Similar and Dissimilar Approaches
Several other approaches used in addiction treatment are quite similar to the model of counseling presented here. Probably the most similar is the Minnesota Model, or what often is referred to as the Hazelden approach. Another popular drug counseling approach that is quite similar is the CENAPS model (Gorski 1989). The 12-step facilitation model (Nowinski et al. 1994), developed for use in the MATCH study (Project MATCH Research Group 1993) sponsored by the National Institute on Alcohol Abuse and Alcoholism, also is similar in its emphasis on the 12-step philosophy and participation.
Other approaches are more dissimilar, such as the traditional Synanon-style approach as provided in a therapeutic community. The difference is not in the content, which might, in fact, be similar, but in the format which, in the therapeutic community situation, would probably be more structured, punitive, and confrontational. Also, our approach is tailored for use in outpatient treatment, so there is no opportunity for immersion in a community, which usually is regarded as a powerful intervention. Another approach that would be dissimilar in both philosophy and content would be any psychotherapy model that does not focus primarily and specifically on changing addictive behaviors, such as psychoanalytic or psychodynamic therapies, including supportive-expressive therapy (Luborsky 1984; Mark and Luborsky 1992) and interpersonal therapy (Rounsaville et al. 1985).
Compatibility With Other Treatments
This counseling approach is highly compatible with most other treatments for addiction. It fits well with many other treatments because it was designed to be a component in a more comprehensive treatment package. Such a treatment program would probably include initial medical and psychosocial assessments, detoxification if necessary, participation in group therapy, psychiatric and medical services if needed, a family support group, possibly employment counseling, and ongoing participation in a self-help program along with the individual addiction counseling. However, this approach to addiction counseling also lends itself well to being used in a private practice format where other types of treatment could be added as desired. For example, it might be combined with family or couples therapy or alternative therapies.
The model can be coordinated easily with pharmacotherapy approaches, whether for treatment of addiction or comorbid psychiatric disorders. While addiction counseling is provided for treatment of cocaine addiction, it is not unusual for patients also to receive antidepressant medication for comorbid depression. Similar counseling also has been used in combination with naltrexone prescribed for alcohol addiction. A trickier situation occurs when a patient being treated for chemical addiction also is being treated for a psychiatric problem with a potentially addictive medication. For example, a patient with cocaine addiction and comorbid panic disorder might be treated legitimately for the panic with a benzodiazepine. In such cases, it is especially important to monitor the use of medication to ensure that it is used appropriately. It is also important, when any medication is being prescribed, to clarify for the patient that being free of any mood-altering chemicals is not intended to include legitimately prescribed medications.