Counseling: Good for Addiction?

When a person asks for help with some issue in his/her life, a safe and relatively common answer is to suggest ‘counseling’. Trouble with your marriage? Get counseling. Depressed? Take an SSRI, sure, but get some counseling too. Kids acting up? Send them for counseling. Wondering about the meaning of life? Lose your job? Have a flight get cancelled? Try some counseling!
What about all of this counseling? Does it do any good? There seems to be this assumption that any counseling is good counseling—but why would that be? The standards for providing ‘counseling’ vary by state, and in some states pretty much anyone can hang a shingle to be a ‘counselor’… What are we talking about when we say ‘get counseling’? 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? Sound good?
In reality 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! Not to mention that there are some real goofy things that pass for counseling, particularly the closer you get to California!
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 often described 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, at a breaking point; expressive therapy would be the choice for a person who wants to develop better insight into how his/her mind works. During psychotherapy in my office, I tend to move back and forth on the continuum depending on how the patient is doing; when the person is struggling the therapy moves in the supportive direction.


What is supportive vs. expressive therapy? This is hard to explain in a short article, but 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 (like psycho-analysis 4 days per week), he will often get worse, even to the point of psychosis.
Looking at it this way, 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’ be the best? I would say no, 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 problem is that the using addict is so full of crap that psychodynamic therapy is generally a waste of everyone’s time. Anyone who knows an addict knows the shallowness of emotion during active use; crying for help as if from the depths of the soul one minute, and then laughing it all off a few minutes later.
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. Specifically, psychiatrists often see addiction as a symptom of something or a consequence 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, wondering if other people feel this way, wondering if he will always feel this way… Usually I explode and say ‘JUST GET AN F-ING JOB ALREADY—WHAT THE F**K!! I’m SOOOO empathic!! I like the addictionologist approach in this setting, including the ‘as if’ approach that I have mentioned before. You don’t feel like working? That is OK—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. And whether you believe it or not, I will help you more by this approach, than by sympathizing with how tired you feel.
This gets to the issue of the harm that the wrong therapy, or the wrong therapist, can do to a patient. If we have a person in treatment who is struggling—nobody is laughing at the cocky, stupid jokes; everyone is calling the person on his ‘stuff’, 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 pretty cool stuff, and pretty 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, maybe also enforcing boundaries… but the great counselors who every treatment center wishes they had are the ones who are addicts themselves, who hate addiction and who come to work ready to rumble every day. It is a game in a way—or 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.
I just mentioned how a ‘softie’ can screw everything up, but 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—a form of self-treatment!’. 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– and this is similar to what ultimately led to my own relapse that destroyed my anesthesia career– you are now a smart guy! You had that therapy, dude! You are da’ MAN! Now you get it, don’t you see—just take a little bit this time—no, a TINY bit!! Just enough to medicate, to take the edge off, then stop!
Right.
I haven’t addressed how the Suboxone issue may play into all of this. I guess I would say that Suboxone lessens the risks just a bit; the ‘addict inside’ is a bit less powerful when the cravings are muted by Suboxone. But I have seen plenty of addicts go from stability on Suboxone back to ‘self medication’ and ‘playing’, and in some cases this folly is fueled by too much ‘self analysis’– which is really code for ‘rationalization’.
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 insight—doesn’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. Another saying—nobody is too dumb for recovery, but some unfortunates are too smart for it.
The best form of therapy by far for addiction is group therapy with other addicts, preferably with a range of sober time including a few ‘old-timers’. And that happens to be an AA or NA meeting. Similar groups set up in treatment centers can work quite well also. Continuing the ‘addict inside’ analogy, everyone in the group has the same addict inside, and now everyone in the group contributes to identifying the addict, calling it out, and helping each other identify the addictive thinking and addictive behaviors that are the tools of the addict inside.
Heavy stuff for Super Bowl Sunday. Anyone who picks the winning team AND the point spread gets a free copy of my soon-to-be-released book, Suboxone, and Addicts Guide, containing an organized version of the information in this blog I must receipt your e-mail by the end of halftime for it to count! To be honest, I’m just curious to see if anyone manages to even make a guess!
Jeffrey T Junig MD PhD
AKA SuboxDoc