Counselor Magazine, Weekly Digest, August 19, 2020
October 22, 2015
Recovery counseling is based on a new paradigm for alcohol and drug counseling. Before I explain this new concept, let’s discuss the model that has dominated the field for over eighty years.
The paradigm that has dominated the field views people suffering from alcoholism and other drug addictions as one self. This model is based on the notion that people who are alcoholics or addicts have been infected by some biological disease-causing process. A version of this idea is voiced in the book of Alcoholics Anonymous where Dr. Silkworth describes alcoholism as “an allergy of the body coupled by an obsession in the mind” (1970).
The disease-causing process alters or changes people into alcoholics or addicts. The results of brain studies are interpreted as validating this notion. NIDA talks about the brain being hijacked by addiction:
Over time, a person’s ability to choose not to take a drug is compromised. This, in large part, is a result of the effects of prolonged drug use on brain functioning, and thus on behavior. Addiction, therefore, is characterized by compulsive drug-craving, seeking, and use that persists even in the face of negative
Two of the major tasks of the alcohol or drug counselor are to educate alcoholics/addicts and their families about the “disease” and to counsel them to enter into life-long recovery. The current thinking is that it is best to approach treating addiction as a chronic illness like hypertension instead of viewing it as an acute medical problem like a broken leg or traumatic head injury.
It follows then that recovery is about developing, integrating, and implementing a program that would help people manage their ongoing vulnerability to addiction. Various counseling techniques and approaches have been developed to achieve this goal:
- Motivational interviewing was developed as a way of helping people develop the motivation necessary to do the “work.”
- Trauma work was focused on resolving painful childhood experiences that dysregulated people.
- Attendance and participation in Twelve Step or mutual help groups was encouraged to provide ongoing support and a methodology to do the “work.”
- Gender responsive treatments were developed to address the unique challenges that men and women face in recovery.
We have come a long way from the barbaric treatment in the early 1900s that was based on public humiliation, ice baths, injections of gold, sanitariums, and shock treatment. But we are still far from achieving the kind of outcomes we’d like. Maybe recovery counseling will add one more missing piece to the puzzle.
Recovery counseling has a very different premise about the nature of people. We agree with the premise that addiction is a disease, but we think of people in a very different way. We believe that people have multiple selves instead of a single self. This difference is quite important and has several implications for our work as alcohol and drug counselors. Let me elaborate on this concept of a population of selves.
Personality DevelopmentWe are born with a large number of possible characteristics and possible selves. We have the capacity to experience a wide arrange or emotions and mental states. We can cry or rage. We can be loving and hateful. We can be brilliant or quite stupid. We can be creative and flexible or fixed and rigid.When these characteristics become woven or grouped into a cluster they become selves. Our selves can manifest themselves in many different ways. They can be loving or gentle or selfish and self-centered. They can be the A-student or the class clown; the jock or the nerd. They can be the life of the party or shy. Our selves can be sexy or puritan. We can be the Gandhi-like or impatient, generous or stingy, vindictive or forgiving. We can be a brave self or cowardly self, a risk-taker or a more conservative self. The list can go on and on. How can all these selves exist in people without driving them nuts? This is an important question that must be answered.All these selves can live together if they can live in harmony rather than in conflict. Mental health, therefore, is best understood as the coordination of all that we are. Healthy people are the ones who have coordinated and found harmony among all of their possible
characteristics and selves. We can say that people who have achieved this mental and emotional state are truly at peace with themselves. Unfortunately, this rarely happens. Instead of integrating and coordinating all of these characteristics and selves into a whole, fully functioning person, we become fragmented and conflicted.
Sometime in our youth we made a decision to shift the focus of our growth away from self-actualization towards actualizing a concept of who we should be. We redirected our growth away from becoming the self that we truly are to becoming an idealized self. We believed this new direction would give us the best chance of belonging, of being loved and accepted. We imagined this would ensure our emotional security, and that we would always feel like we belonged rather than feel alone or isolated.
We pay a huge price for this shift in our growth force. As Dr. Karen Horney noted, the development of the phony self is always at the expense of the true self (1991). We lose ourselves to protect ourselves and to ensure or existence. What a paradox!
In order to actualize the concept of who we should be we emphasize some personal characteristics or selves at the expense of others. Some selves are essential in organizing our personalities along the lines delineated by the concept who we should be. Other selves or characteristics might be desirable but non-essential and still other characteristics or selves will be disowned and rejected because they are unwelcome guests.
This means that the goal of therapy is to liberate the constructive forces of the real self which will result in a more integrated, more appropriately organized personality that functions better under any condition whatsoever.
Let’s see what happens when a person becomes an alcoholic or addict.
The “Addict Self” and “Recovery Self”
Brain research has clearly demonstrated that the brain is hijacked by addiction. This means that all of the various functions of the brain are recruited to support the use and abuse of drugs. As the brain conspires to support the addiction it reorganizes the personality to include a self that drinks or uses. As the disease of addiction progresses, this drinking or using self becomes crystallized into the “addict self.”
The addict self is how the disease manifests itself in the personality. Once the addict self ascends to the top-dog position in the personality, it runs the entire show. The addict self decides to drink or use regardless of consequences. It is the addict self that drives people to go to any lengths to get high and fight to protect the right to drink or use. Upon being confronted, the addict self turns reality around to create confusion and doubt in others, much like the octopus uses ink as a defense. The addict self is toxic, scheming,
manipulative, and dishonest. Its major purpose is to ensure addicts’ access to their drug of choice.
What happens is that people quickly lose sight of their other selves; the ones that the addict self has deemed as nonessential. At some point in the progression of the disease, alcoholics/addicts lose sight of the fact that they are more than their disease. A complete identification with the addict self occurs. Therefore, any threat to the addict self feels like a threat to one’s very existence. It would be most accurate to say that people suffering from addiction have lost themselves to the addict self, that their personality has been hijacked by addiction. This is the why we define recovery as the recovery of the lost, true self.
The “recovery self” is the antithesis of the addict self. This is the part of people that wants a better life—this is the healer, the compassionate one, the wise self, the seeker, the healthy self. This part will help recover the lost, true self, if it is integrated into a client’s personality. This part seeks wholeness, integrity, and spirituality.
The recovery self is focused on and committed to getting well, and to taking whatever action is necessary for the restoration, redemption, and salvation of the lost, true self. The recovery self reinstates the process of self-actualization.
Some Implications for Counseling
One of the first things I try to do is to form a therapeutic alliance with the recovery self. I facilitate this alliance by introducing these concepts to clients and by encouraging them to try an experiment that creates a dialogue between the addict self and the recovery self.
Needless to say timing is critical when proposing an experiential intervention like this. I rarely enter a session with this agenda in mind. Rather I see my job as following my clients, tracking where they are going or where they need to go. I lead from behind.
I tell my students to listen to what clients are unable to say. This provides an answer to the question: What is missing? What is missing in clients’ presentations is a clue to what is needed. Fragmentation creates fixed and rigid responses. These fixed and rigid responses decrease people’s possible responses to a problem. What people can’t do reflects who they are not. This is the working point I search for during our encounter.
Usually the opportunity to introduce this particular intervention—the addict self to recovery self-dialogue—arises when clients present with an urge to drink or use.
As the dialogue unfolds it becomes quite obvious how the selves are connected and organized. In early recovery the addict self is in charge and the recovery self often pleads with the addict self to leave them alone or takes a more aggressive approach. Both of these responses are ineffective—pleading with the addict self and demanding that the addict leave will not create change. Change will be forthcoming when these two selves are better coordinated. This means that recovery starts with acceptance that the addict self is there to stay and that the problem has been that clients have abdicated responsibility for their lives to this part of themselves. This becomes a very powerful realization. Once clients accept that this is a part of them, and that they will have to deal with this for the remainder of their lives, then real change and recovery can begin. This is the paradoxical theory of change that is at the heart of this approach to counseling.
Protocol for the Recovery Addict Self-Dialogue
I have summarized the protocol for this intervention so you can get an in-depth look into what it entails.
Laying the Groundwork
Initially I describe in quite general terms the notion that we all have a population of various selves that exist within, and most importantly that mental health is the coordination of all that we are.
Once this groundwork is laid, I then speak more specifically to the concept of an addict self and recovery self and the importance of learning to deal with the addict self.
This is very important in establishing a therapeutic alliance.
To accomplish consensus I ask clients if they are willing to try an experiment. If they express any hesitation I ask them to discuss what is causing this reaction to see if I can help them work through their resistance.
Introducing and Describing the Experiment
If clients agree to try the experiment I then describe the specific details of what I had in mind. Don’t think of these first three tasks as independent; they are not. When you are doing the first task you are also describing the experiment. The important thing to keep in mind is to tell clients exactly what you want them to do.
Introduce the two chairs that clients will shuttle between and ask them to identify the chair that will represent their addict self or recovery self. Then identify the other chair as representing the other side of the dialogue. Next I ask clients to tell me which side they want to begin the exercise from. Have them occupy the chair that represents that self.
I tell clients that I want them to have a dialogue between these two parts of themselves to help them become aware of how they relate to one another. You can say something like, “Just write a script between them spontaneously. I’ll tell you when to change chairs, but after a few moments you may decide when you want to shift and answer from the other side of you.”
These first three steps don’t usually take a lot of time, but sometimes they might. Use as much time as needed, but as little as possible. You want to move into doing rather than continuing to talk as soon as possible.
Enacting the Experiment
This step involves moving into action.
I have clients begin the exercise. Once they have made a statement from the first position or asked a question to the other side, I have them change and respond.
Don’t be anxious about having them change. Make certain they have expressed what is most important before changing to respond from the other side. On the other hand, don’t let clients have long-winded monologues either. You want to encourage and stimulate a lively interchange.
Knowing when to have them change sides will find a natural rhythm as the experience unfolds.
The goal here is to promote awareness; remember that the obvious won’t seem so to clients.
After several exchanges I may ask clients to hit the pause button and ask them what they are aware of. If I see clients having a strong reaction that they are ignoring, I might say something like, “What are you experiencing right now?” or “Can you put some words to what is happening in your eyes or throat or _____?”
Many of the Gestalt interventions that are directed at either suppressing avoidance or encouraging expression are useful during this phase of work.
Identifying What is Missing
What I am concerned with here is identifying what I call the “working point.” The working point relates to that issue or process that has come to the foreground. This issue is related to what is missing and reveals the hole in clients’ functioning. In the background of my mind I am constantly asking myself what is missing or what the clients need to do to take better care of themselves or resolve the current dilemma or conflict.
At the right time—meaning after clients have established the working point—I ask clients if I can share my observations with them. This often leads to another experiment in which I have them try on different attitudes or strategies that have the intent of adding what is missing.
When I introduce an experiment within the experiment I am constantly checking in with clients to see what their experience is telling them about what they are doing. Learning is discovering new possibilities. In this particular case it is about learning new ways of dealing with the addict self. Often the problem they are having in their recovery is that they have deferred to the addict self and have become very passive in dealing with that part of themselves.
At this point in the session I am thinking about integrating or helping clients reorganize themselves so that these two selves are better coordinated. This is an essential step if the person is able to establish stable, long-term recovery from their addiction.
Integration occurs when the parts are no longer polarized, and oftentimes exaggerating the polarization will organically lead to integration.
Debriefing and Closure
You will have a clear sense of when integration or a better rearrangement of the selves has occurred. After I sense this shift I explore what the experience means to clients, such as what they have learned about themselves and what they need for their recovery.
Sometimes I might explore how the addict self might sabotage the experience. If I sense that there is a strong possibility of sabotage, I might actually ask clients to be the addict self and tell me how they are going to sabotage the work we did.
The important thing here is for me to feel complete and check in with clients to see if they feel this way too. If not, and there is time, we have more work to do.
Things to Keep in Mind
Here are some points to keep in mind when going through the intervention. Challenge Incongruities
Keep an eye open for discrepancies between what a person says and what they are doing. For instance, if someone says they are “angry” and they say it matter of fact, point this out. Ensure that the music matches the words. Say something like, “You say you’re angry, but you don’t sound angry.” This will then lead to a discussion which will help you identify what you need to do next.
Exaggerate the Issue when a Person is Stuck
When a person is at an impasse during this work you can intervene by having them exaggerate their current posture or behavior. For instance, if someone responds in a very low voice, make them aware that they are whispering and ask them to exaggerate their response and whisper even more softly. This will typically move them into a greater presence and make their feeling even more accessible.
Search for the Missing Response
It is extremely important to be aware of what is not happening at the same time you are paying attention to what is happening in the session. It’s amazing how what seems to be conspicuously absent is not at all obvious to clients. That is because they have a blind spot; they can’t see what they don’t know or they might not want to see it. In either case, pointing out what is missing can be a very powerful intervention and can open up a set of new possibilities.
For example, if during a dialogue between the addict self and the recovery self you see clients avoiding the addict self, point it out. Say something like, “I want you to be aware of how you are avoiding what your addiction is saying to you.” Later in the session, if they are continuing their avoidance, you might introduce the opposite and say something
like, “I’d like you to experiment with something: respond to what your addiction is saying and let’s see what happens.” An alternative to this intervention is to have clients exaggerate their avoidance like I previously described, such as, “Tell your addiction that you are avoiding him, and that you don’t want to deal with him.” This is also extremely effective.
Ask for What You Want
Be direct and clear in your requests or direction. Don’t fall in to the trap of assuming that your clients know what you want. If they look towards you during the interaction with a part of themselves, redirect them: “Tell that part of you what you just said to me.” Be tenacious in your position and don’t let therapy turn into a social conversation.
Flow with What is Happening
Don’t force it; trust the process and allow it to unfold naturally as you monitor what clients are doing from one moment to the next. What is happening right now is the most important issue to focus on and deal with in therapy. Change occurs by dealing with what is happening right now.
Remember This is An Experiment
There is no right or wrong result. Focus on learning from what is happening rather than getting hung up on expecting a particular outcome.
Help Clients Loosen up
The more open and willing clients are, the better chance they will have in discovering a solution to their addiction.
The goal of recovery counseling is the coordination of all that people are to work towards establishing the internal resources to manage their ongoing vulnerability to the addict self as well as the reinstatement of self-actualization. In this article I have discussed just one of the interventions that are designed to facilitate this process.
Alcoholics Anonymous World Services. (1970). Alcoholics Anonymous. New York, NY: Author.
Horney, K. (1991). Neurosis and human growth: The struggle toward self- realization. New York, NY: WW Norton & Company.
National Institute on Drug Abuse (NIDA). (2007). Understanding drug abuse and addiction: What science says: 2. Drug addiction: A complex illness. Retrieved from https://www.drugabuse.gov/publications/teaching-packets/understanding-drug-abuse- addiction/section-i/2-drug-addiction-complex-illness