Back to Basics

So what really drives our clinical decisions in the field of addiction? How do we end up ascribing to a particular clinical philosophy, therapeutic approach, or modality? Our graduate education, early career mentors, and entry level experience could definitely have played a major role in our professional identity. But at the same time, we must go back to basics and ask the fundamental questions that have profoundly shaped us as addiction professionals.

These fundamental questions are:

1. What do I think addiction is?
2. How do I think addiction develops and is maintained?
3. How does one recover from addiction?

Those entering the field as university students hold ideas in regards to their answers to these questions. It is also important to consider the prevalence of individuals in recovery themselves who enter the field of addiction treatment. They have their answers to these questions as well. And sometimes, these answers are held with strong conviction.

We know that the answer to these fundamental questions could have been informed by society, by family experience with addiction, by personal experience with addiction, and by media exposure; all these, even prior to any formal education on the topic.

A common pathway for those entering the field is to ascribe to a therapeutic approach or modality that validates their pre-existing answers to the fundamental questions. We can be quick to cherry pick research findings that support what I already knew. And this is OK. You would want the work you do to be aligned with your personal beliefs. In this sense, the person is attempting to reduce cognitive dissonance.

We could imagine the differences in answers to the fundamental questions between a professional that believes in abstinence based recovery versus one that believes in harm reduction. Between one that believes in an acute model of care versus one that believes in long term self-management.

As one progresses through their professional development, one could be encountered with diverse therapeutic approaches, shifts in society’s view, a supervisor that will push the envelope in a different direction, new research, and maybe a different job that implements a different clinical philosophy. The one constant is change.

Can I allow my answers to the fundamental questions to grow and change over time? Do I still believe addiction is the same concept I believed in 20 years ago? Do I still believe people recover in exactly the same way as how I thought when my career began? Or am I changing and evolving my views?

How we remain open minded and are able to embrace this change becomes a necessity in our fast-evolving world. Not only for our professional sake, but more so for those we serve. At the end of the day, it becomes a question of ethics.

This is not only an addiction professional issue. Those we serve, our clients, are also fellow travelers in this journey. They also present themselves to the treatment episode with answers to the fundamental questions of what they believe addiction is, how it was developed and maintained in their specific cases, and what they could do to recover. The answers to these questions are not always overt or ordered neatly in their minds, but even in cases as such there are underlying beliefs about these issues that directly affect their engagement in treatment.

The work that I can do as a helping professional in understanding the client’s answers through their perspective can go a long way in the development of the therapeutic alliance and in a positive outcome. How flexible and adjustable I can be as the professional is key. For this flexibility to seem authentic as it translates to a helping relationship, I must have been witness to diverse experiences that can enrich my capacity for multi-level empathy.

As you close your eyes and reflect, how can you answer what addiction really means to you today? How do you think it develops? And how do you think people really recover? The answers really matter to what we do as helping professionals and to those that seek our help.

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Increase your happiness in a powerful way: Gratitude

Knock, knock. Who’s there? It’s gratitude!

One day, a few years ago, I was directed towards a challenge: I was asked to think about a person that had been kind and had done something beneficial for me, but that I had not thanked properly. I was told I could think far back into my life, but to think of someone who was still alive.

After reflecting for some time, I began to think about a high school teacher that had been particularly impactful for my life and my world view. I remembered how this teacher challenged my thinking and helped me remain true to myself and my opinions. He was for sure not part of the status quo; a man not afraid to shake it up and get in a little trouble while doing so.

So I wrote a letter that described the profound impact this teacher had on me and my history. I looked this person up and I found a university newspaper article from Ohio which was titled “He’s not your usual professor.” Before starting to read, I knew it was him. I wrote an e-mail and we establish contact.

Luckily enough, we were able to set up a meeting for dinner. I had my chance. I expressed openly and whole-heartedly the content of my letter. It was a highly emotional experience for me. I felt overwhelmed with gratitude and joy. The experience helped me realize that I had not been alone, not only as it related to this encounter but with many others in my life. There had always been individuals that had help guide my path, although I had not been aware of it at the time.

The man sitting in front of me, my teacher, seemed taken by what was going on. He responded by saying that he had no idea of the impact he had on my life. After seeing hundreds, if not thousands, of students in the previous eighteen years it could be difficult to discern who got the message and who did not. I hope he understood how his message transcended with me and is still with me in some shape or form.

This exercise I was challenged to complete is called “The Gratitude Visit.” If you feel up to it, maybe you can give it a try. Research has shown that this exercise provides a strong boost in happiness and a decrease in depressive symptoms after a person completes the exercise.

As a summary, the steps to follow are:

• Think of a person that is alive and that has done something positive for you. You have not thanked this person properly.
• Write a letter describing what the person did and how this has been beneficial for you. The letter could be about a page or page and a half.
• Contact the person and schedule a visit to deliver the letter and express its contents. Try to do this within one week if possible.
• Reflect on how this exercise made you feel.

Those in recovery from addiction are used to scheduling a time to admit their wrongs and “make amends.” That is an essential component of 12 step recovery. But reaching out to those that have been positively influential in our lives also seems a worthwhile effort that can contribute to our recovery and well-being.

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So you found the cause of addiction?

The complexities of addiction have long been compounded by all the discussions about what addiction is, how it develops, and the factors behind this development. Parallel to this is the discussion on how to better address addiction. Of course, these proposals on treatment and recovery are directly related to the answers someone might have in regards to the first set of discussions: what it is, how it develops, and the factors behind this development. I would term this, someone’s “personal philosophy of addiction.”

Some of the common discussions include the role of genetics, the role of social factors, the role of neurobiology, the role of learned behavior, the role of co-occurring disorders, and the role of childhood experiences. The weight a person would place on any of these factors would inform their “personal philosophy of addiction.”

Once a person has formed their “personal philosophy of addiction”, they could have a sense of what would provide a better alternative on how to address this issue. Do I believe addiction is mostly a direct result of childhood experiences that included trauma? Then I would probably place priority emphasis on the resolution of this issue as it relates to treatment and recovery. Examples as such can be made with all other factors.

When proponents of single factors that explain addiction are making their points, they usually do a great job providing rationale and isolating the factor in such a way that it provides a great opportunity of enriching knowledge on the influence this factor has on addiction. Their intention is a noble one as they attempt to find a better solution to this problem by exploring its root causes and underlying conditions.

The problem in this occurs when a proposal as such does not consider a context in which this factor interacts with many others. Reducing our understanding of addiction to one single explanation is not warranted in our attempt to improve the way we help those afflicted by addiction.

Discussion around these topics tends to be based on premises of mutual exclusivity. If this is right, then that must be wrong.

I believe the discussions should be about increasing our knowledge base and understanding. It should be about integration between all the great things we have learned so far about addiction with all the new perspectives.

Can addiction be a disease of the brain while also having been influenced by social factors and adverse childhood experiences? Why not.

One critical factor not to be left out of the conversation is the person struggling with addiction issues themselves. Each person has a story and a narrative. What could be the perceived causes of one’s addiction could be totally different that the perceived causes of somebody else’s. So let’s listen to them. Let’s try to understand where they are coming from and what they believe in. Let’s also listen to how they believe they can recover. At the end of the day, what the person struggling with addiction believes about all this is more relevant than what I believe as a helper.

Many speak about person-centered approaches, individualized treatment, integrated behavioral health, bio-psycho-social-spiritual approaches, holistic, and whole-body perspectives. Do we really believe it? Does it really show in what we do to help those in need? What do I honestly believe about addiction, how it develops, and how people recover? The answers make a world of difference.

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The Neglected Side of Step Four (of AA/NA) – Character Strengths

The 12 steps of Alcoholics Anonymous/Narcotics Anonymous (AA/NA) are not the only pathway to recovery. But for those that decide to take the journey, it will be known how the fourth step (Made a searching and moral inventory of ourselves) has built a reputation as one of the most spoken about in fellowship meetings, step study resources, conferences, and other AA/NA activities.

This reputation is also related to the perceived difficulty some members of 12 step fellowships have attributed to the fourth step. In this inventory, the person addresses issues related to resentments, fear, relationships, guilt, and shame; all areas that can prove challenging to a person in early recovery. It includes the identification of the role of the character defects.

A person in this state has traditionally coped with these difficult areas through the use of the substance and/or other unhealthy behaviors. Now in abstinence based recovery, the individual could be faced with emotions that are difficult to understand and to face in a newly found life of sobriety. Some could avoid reaching this point and many a self-esteem could be shaken.

The development of addiction itself could have been influenced by adverse childhood experiences, mental health conditions, and unhealthy family dynamics. At the same time, and through the progression of addiction, additional negative consequences can arise: worsening of mental health issues, additional traumatic experiences, relationship issues, etc. It could be easy for the person to forget or not recognize what is inherently good in them.

What about if more attention would be given to the person’s assets, positive traits, or character strengths? Could this shed some light to help individuals identify and recognize in themselves positive aspects of their personalities and their lives that could have easily been obscured by addiction? The Narcotics Anonymous Basic Text makes explicit reference to this point:

“Assets must also be considered, if we are to get an accurate and complete picture of ourselves. This is very difficult for most of us, because it is hard to accept that we have good qualities. However, we all have assets, many of them newly found in the program…”

One specific way in helping to achieve the identification of a person’s character strengths is through the use of the VIA Survey of Character Strengths ( www.viasurvey.org ). These character strengths are based on Petersen and Seligman’s (2004) Character Strengths and Virtues: A Handbook and Classification. In this classification, there are six human virtues that are common throughout cultures along with twenty-four character strengths.

Among the virtues and character strengths (character strengths in parenthesis) we can find wisdom (judgment, perspective), courage (honesty, bravery, perseverance), humanity (love, kindness), justice (fairness, teamwork), temperance (humility, self-regulation), and transcendence (gratitude, hope, spirituality). These character strengths are common topics of AA/NA culture.

“Character Strengths are the positive parts of your personality that impact how you think, feel and behave and are the keys to you being your best self…They are different than your other strengths, such as your unique skills, talents, interests and resources, because character strengths reflect the “real” you — who you are at your core.”

VIA Institute on Character

Through the use of the VIA Survey, a person can find the order of importance of their character strengths. The awareness of the existence of these character strengths, along with the practice of employing these strengths in new ways, can help a person overcome the emotional burden when coming face to face with the person’s defects of character. The awareness of our character strengths can also provide for a hopeful future when things are not looking too bright while realizing that there is good in me. You could see how this could be beneficial even if your pathway to recovery is not through the 12 steps.

You can access the free survey at www.viasurvey.org and expect to take about 15 minutes to complete it. If you are a clinician in the field, this can prove a great tool for many individuals that have difficulty in seeing the good in themselves.

The idea is not how one perspective is better than the other in regards to character strengths versus character defects, but how both supplement each other and could help individuals obtain a more balanced view of themselves and their histories with both virtues and difficult areas; the true nature of step four.

Do you know what your strengths are?

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Ohhh noooo!! It’s a difficult client!!

So how do we react to the difficult inpatient client in our caseload? That person who acts defiantly, does not comply, seems that does not want to be there, but is. Other peers in treatment are not too keen of this client and neither is staff. Does the client follow programming? Not quite.

This scenario presents a challenge to clinicians, staff, and others participating in treatment. The client behaves in such a way that gets under everyone’s skin but is not doing enough to have their treatment terminated. Every morning the news on how clients are doing revolves around this specific person. Whaaaat now? What did the client do (or didn’t do) this time?

How is the psychic and morale of the clinician affected? Do we wish this client wasn’t here anymore? Can insurance please deny further coverage? Can we just kick this person out?

Helping the client engage in treatment can be a work in progress while meeting the client where they are at can also be challenging without the support of other staff who want you, the primary clinician, to “fix the client”. Wishing this client not be in treatment can seem like the best out, but many dynamics must be addressed if we are to remain true to the importance of patient care and ethical practice.

In an individual sense, the clinician must be aware of feelings arising from the situation, be it transference related or due to pressures from others involved. In group settings where staff is present discussing the case, the clinician must be aware of how others’ comments affect their own perspective of the situation and of the individual. Are we buying into the groupthink or are we able to maintain our individual opinions?

They all deserve the best from us, always and unconditionally, whether we like them or not, independent of our opinion, and independent of our professional prognosis.

The need for supervision seems paramount in cases as such. Easy answers should not be expected as there are many factors to consider. But if we are to speak about client care and ethical practice as a priority, the following points are of relevance:

While the client is still in treatment and under our care, this person deserves nothing but the best from us and our team. That is the warranted client care. The possibility of assessing whether the client should be in this treatment episode, or not, becomes a different conversation. Until, and if, a decision as such is made, the client is still a client, no matter anything else.

Am I as a clinician aware of the power of my expectations of the client, on the client’s outcome? There is a chance of closing down possibilities to be helpful if my expectations of this client are minimal or non-existent; if I am not as present as I can be for this person; if “I know this client will fail, so why try”. They all deserve the best from us, always and unconditionally, whether we like them or not, independent of our opinion, and independent of our professional prognosis.

Picture this scenario: I take my car for a tune-up, but I am not one of those to really take good care of the car nor to follow all preventive care suggestions. It is also a bit dirty and filled with fast food reminders. How would I feel if I found out I was not given “the usual tune up” they give everyone else because the mechanics thought I did not deserve it for not taking good care of my car? I did pay the same amount as the “worthy ones”. I don’t know about you guys, but I would not be a happy camper.

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