The Importance of Counseling

Not to open up a controversy or anything… but there is considerable disagreement between physicians in principle and in practice over the importance of ‘counseling’. 

To define our discussion, ‘counseling’ is used to refer to everything from one-on-one psychotherapy to group therapy to twelve step programs.  I am going to try to be more pointed and brief than my usual blah blah blah style;   I would be happy to argue the point ad nauseum at someone else’s expense, but I simply have too much work to do today. 

My feelings about counseling:

– A century of Recovery experience has taught us that psychiatrists and therapists have a horrible record of ‘talking’ people clean.  There is a common MISconception among lay persons that addiction comes from underlying psychopathology, and if you ‘fix’ the underlying problems, the addiction will ‘go away’.  This is the stuff of movies and fantasies– not a medical reality. 

Addiction is a PRIMARY disorder– it is not SECONDARY to something else.  Yes, many addicts have emotional baggage– and so do non-addicts.  Many addicts have perfect upbringing, if there is such a thing.   It doesn’t matter.  Once a person has become an ‘opiate addict’, the addiction is the MAIN thing, and must be treated first.  You won’t fix depression or anxiety in an opiate addict by therapy or meds or anything else until the addiction is in remission.  It makes no sense to water the houseplants while the house is burning down.

– Add that ‘counseling’ for bupe patients consists of going through the same classes and groups as the people NOT on buprenorphine.  This is an unexamined treatment strategy that makes sense in a superficial way, but makes little sense if one looks at what happens during group therapy and step meetings. 

Support groups  use the forces of peer pressure in a positive way;  the addict who relapses is letting down not only himself, but also a group of people who he will have to face and admit his error.  If a group consists entirely of people on Suboxone I could see some value, provided everyone had the same goal in mind. 

But in practice, patients on bupe are often placed in groups that include addicts not on bupe, and that is a recipe for disaster.  In such cases you will have compliance problems with the patients on buprenorphine.  You will have envy, snobbery or anger by the people not on buprenorphine.  And you will have all kinds of bad behavior in the parking lot–  addicts ‘helping’ fellow addicts by sharing their medication, etc.

– Step programs work by changing personality– something that is rare and very difficult.  Most patients who try the steps never ‘get’ it.  Those who do are lucky indeed–  and they get there because they are so desperate that their minds open to a new perception of things.  Treatment is NOT education.  I love the saying ‘insight maketh a bloody entrance’ in regard to treatment.  If a person in treatment is happy and comfortable, he is not going to stay clean after leaving. 

The right person for AA or NA is a person who is sick, tired, humbled, and desperate– as it says in the AA readings, ‘only when a person clings to recovery as a drowning man seizes a life preserver’.  People on buprenorphine are NOT desperate– not in this way, and not to this degree.  They may have debt, may be alone and lonely, may be broke and unemployed… but they are no longer in the state of utter desperation that they were before buprenorphine. 

Making a person who takes buprenorphine attend step meetings FEELS good, but is probably a waste of time and energy for everyone involved.  If a person WANTS to go, more power to him– but that is a completely different situation, as at least then you have a person who is interested in being there– not as good as being ‘desperate’, but better than being forced into going.

– Lest you interpret my comments to mean that a person is worse off by losing that desperation, that is NOT what I am saying–  because the success rate for staying clean using the steps or other components of residential treatment is very LOW when you look at opiate dependence.  I have been told I shouldn’t say this, as it takes away ‘hope’– but ‘hope’ ain’t all it is cracked up to be, at least when it comes to addiction.  Addicts USE hope to avoid getting clean.  Freedom from addiction comes when the person is hopeless. 

If you are currently using, you are probably familiar with ‘hope’-  that is what allows you to take another hit!  You ‘hope’ that some day things will be different.  You hope that you will get your act together.

The success rate for ‘traditional’, non-buprenorphine treatment has always been very low– not a huge crisis when we are talking about a few heroin junkies, but now that we have an epidemic, we cannot settle for a 80-90% failure rate!

—The good news is that we now have something that will induce remission from active addiction WITHOUT requiring the near-impossible change of personality that used to be required to stay alive.  It is a mistake to think that we should mix both treatment strategies together. 

For the reasons I have outlined, buprenorphine and the steps are more of an ‘either/or’ situation.  We used to treat depression by sending people to treatment centers (country spas for rich women;  horrible locked wards for the less fortunate).  Treatments consisted of ECT and even lobotomies.  Now we have Prozac.

—Everybody has character defects.  When we only had the steps to treat addiction, we HAD to address the character defects and ‘change’ the addict’s personality.  The problem is that personality always changes back when the person stops attending meetings– so the addict in traditional recovery MUST keep going to meetings, or the old addict simply comes back. 

With buprenorphine, the entire paradigm has changed.  Correction of character defects is a good thing… but I doubt it will happen with a person who is NOT DESPERATE.  Plus, I have been surprised at the extent to which character defects resolve from buprenorphine alone– leading me to see character as more fluid than I used to.  In other words, the constant obsession for opiates creates dishonesty and self-centeredness… and just removing the obsession has the effect of removing those defects!  

This is a totally different way of thinking about addiction and character defects– and the time has come for this change in perspective.  With this new perspective, my question becomes… why do we force the addict to jump through all the hoops of trying to change his ‘character’ as a prerequisite to treatment with medication?!  

If a person wants treatment for heart disease, do we FORCE character change before prescribing medication?  Do we FORCE a change in diet, or nutritional counseling?  Do we FORCE sobriety from nicotine before giving nitrates for an impending heart attack?

Of course not.

The requirement for ‘counseling’ is sometimes– not always– an example and a consequence of the stigma of addiction.  Addiction is a DISEASE, and we finally have a TREATMENT that works.  Yes, I encourage addicts to look at their character defects.  I also encourage doctors to look at THEIR character defects. 

But I also suggest that addicts who are staying clean using the steps stay focused on their OWN inventories(!)