Is Counseling Good for Addiction?
There is a general assumption that 'counseling' is always a good thing. When one considers that counseling often consists of advice from a stranger, perhaps it is just as well that people rarely act on such recommendations. This article examines types of counseling, and discusses the usefulness of counseling specifically as part of the treatment of addiction. The conclusions may surprise you.
When a person asks for help with some issue in his/her life, a safe answer is to suggest counseling. Trouble with your marriage? Get counseling. Kids acting up? Send them for counseling. Have a flight get cancelled? Try some counseling!
There seems to be this assumption that any counseling is good counseling? But why would that be? What if we take the word counseling and change it to a different word with the same meaning; do we still feel the same way? For example, by counseling I think most people mean interacting with another person, and receiving feedback in the form of interpretation, clarification, or advice. How would you feel about the idea that if your kids are acting up, you should send them to a stranger and have the stranger give them advice?
There is no shortage of bad advice out there, so why is there an assumption that advice is OK, as long as someone is calling it counseling? One could say that there is the assumption that a counselor has had training, and therefore the advice will be better than the random advice one typically receives from strangers. But we all know bad doctors, and the standards to become a doctor are incredibly stringent compared to those for counseling!
There is one thing about counseling that does guarantee a certain degree of safety-- any recommendation to undergo counseling is usually ignored! But in all seriousness, the people who are referred for counseling are often vulnerable, and so the issue of whether to blindly send them for advice from strangers does deserve some consideration.
There are, of course, different types of counseling. The counseling done by advanced-degree practitioners, such as psychiatrists and psychologists, is generally referred to as therapy rather than counseling. Therapy can be broken down into different types, and some conditions are more responsive to one type of therapy than another. Therapy is placed along a continuum from supportive therapy on one end to expressive therapy on the other. Supportive therapy would be the appropriate approach for a person undergoing trauma or significant stressors; expressive therapy would be the choice for a person who wants to develop better insight into how his/her mind works.
What is supportive vs. expressive therapy? Supportive therapy is aimed at strengthening the person's defense mechanisms, as those defenses are what keep us sane during times of stress. Expressive therapy, on the other hand, is aimed at questioning assumptions, digging up repressed content, challenging long-held impressions of relationships, etc. If a person is already under a great deal of stress, and then undertakes frequent sessions of expressive therapy, he will often get worse, even to the point of psychosis.
Undergoing therapy during active addiction at first seems to suggest some contradictions. During addiction the addict is very stressed out, so wouldn't that suggest that supportive therapy would be best? Absolutely not-- when treating addiction, I WANT the person to question the assumptions and rationalizations that keep the person using. So does that mean that expressive, psychodynamic psychotherapy would be a good idea? To that I would also say no. The using addict is so full of BS that psychodynamic therapy is generally a waste of time.
There are other problems with therapy during addiction, even in recovery. A psychiatrist may see addiction in a way that runs counter to the view of an addictionologist. Psychiatrists often see addiction as a symptom of something; addictionologists on the other hand see addiction as a primary disorder, that may be the cause of psychiatric symptoms or illness. To one, addiction is a chicken, to the other, an egg!
The addictionologist worries that the addict in therapy will start to find reasons for what he is doing, when the reasons aren't the issue; the point is to just stop doing it! I get this image of two extremes among my patients; both have a month of sobriety and it is time to be working full time, and one says 'OK' and starts filling out applications without even thinking about the nature of the job, and the other sits for weeks talking about how it 'feels' to go back to work, wondering why it feels this way, and wondering if he will always feel this way. I like the addictionologist approach in this setting, including the 'as if' approach that I have mentioned before. You don't feel like working? Just act as if you DO feel like working, and get to work. You feel tired? Act as if you don't feel tired. To a tired, nonworking person this sounds harsh; but I am only trying to help.
This gets to the issue of the harm that the wrong therapy or therapist, can do to a patient. If we have a person in treatment who is struggling-- nobody is laughing at the cocky, stupid jokes and he is getting close to that place where he drops the cocky attitude and brings his genuine self to the treatment scene-- If at that point, a sensitive, kind therapist came on the scene and started making little 'poor baby' faces with the person, that could completely destroy the treatment. Addiction treatment is challenging-- it takes a person who can distinguish the real person and the BS person, and use the BS person's own words back on him to try to break though the cocky front. This is the work of a good addiction counselor. There are plenty of counselors who think they are treating addiction by providing education and support, but the great counselors are the ones who are addicts themselves, who hate addiction and who come to work ready to rumble every day. In a way it is like a chess match. Knowing how hard to push, and when to push a bit harder, and then knowing when to shift gears and reel in the newly-opened mind. It is tiring work, and given that we are literally talking about saving lives, the pay is not near good enough.
There are other dangers to therapy for those in recovery from addictions. All of us in recovery have what I like to think of as 'the addict inside.' The addict is there for one reason-- to get us to use. The addict is crafty, or as they say in AA, cunning, baffling, and powerful. The addict inside has advantages over our sober selves; the addict has access to all of our minds, including our unconscious, where our fears, lusts, prejudices, hatreds, and other powerful forces reside. The addict can use these unconscious feelings to push us to do things that may ultimately destroy us. But our sober selves have our own advantages; we get to control our arms and our legs. Sure, the addict inside can push us up down, left, right, into using once we are in a dirty bar at 3 AM; but our legs can carry our sorry heads to the edge of the bed at 10 PM and then drop us there, so that we can't get near that bar! The problem with therapy is that is does at least two things to strengthen the 'addict inside'. First, the addict LOVES to talk; you start up that therapy, and the addict gets to start up with all the BS, and given free rein the addict will win over logic every time. The second thing is that the addict will use confidence of our sober selves to the addict's advantage, like this: 'I see it now! I used because I was teased on the playground, and that created this pain in my heart that never went away-- so I needed a pain killer, and I took one, to ease the pain! Sounds pretty logical-- but you have just told the addict in you about a big weakness. The next time you are in a situation that is somehow similar to being teased at the playground, the addict will be ready to tell you about how much you hurt, and about how good it would feel to medicate the pain, and about how much you deserve to be medicated. And even more-- you are now a smart guy! You had that therapy, and so you are probably OK to use just a little bit!
I am not totally down on therapy for addiction. Just don't kid yourself. One of my favorite lines from the movies is still number one, a couple decades after when the movie came out--Clint Eastwood saying 'A good man knows his limitations'. This is important advice to any addict who would like to stay clean. Know your limitations. Having psychotherapy--even real good psychotherapy that truly adds insightdoesn't make you any safer. If anything, it increases the risk that you will talk rings around yourself some day and get into more trouble. I'll close with another wise saying-- nobody is too dumb for recovery, but some unfortunates are too smart for it.
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ABOUT THE AUTHOR
Jeffrey T Junig MD PhD has worked as a neuroscientist and as an anesthesiologist, and is a psychiatrist in solo, independent practice. Information about opiate addiction treatment options and Suboxone treatment can be found at his web site, http://soberaftersub.com. Dr. Junig is available for patient care, consultations, or educational presentations through http://fdlpsychiatry.com.