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The Addiction Therapist’s Guide to the 21st Century

You may have to unlearn much of what you have been trained to do.

Drug use is being legalized in the United States, and it’s causing fewer personal and social problems than we imagined. In Colorado, traffic fatalities and crime were down in 2014, the first year of legalized marijuana. In California, results were similar under its 2010 decriminalization (reduction to a violation and small fine) of marijuana possession – leading to the 2014 passage of Proposition 47, which decriminalized cocaine, meth, and heroin possession.

What is clear is that drug use, on its own, is no longer considered a pathology or a problem. Indeed, this has been recognized by DSM-IV and -5, both of which categorize substance use disorders (SUDs) in terms of problems caused by use of any substance, and not simply consumption of special categories of drugs. This is also true for relapses. While AA regards any use as falling off the wagon, DSM requires the demonstration of a problem in order to categorize a person as having a relapse. The meaning of what 12-steppers call being in recovery or sober, both of which are misnomers as typically used, has changed.

In this new substance use world, here are five prevailing principles for counselors to remember in treatment:

  • Harm reduction is the aim.

If you, as a therapist, are incapable of dealing with clients on this [harm reduction] basis, you are in the wrong business in the 21st Century.-Stanton Peele

Without our abstinence fixation to guide treatment, we need instead to always examine the harms any substance is causing a person. If they drink and drive, or take drugs and have sex, how can they forestall problematic behaviors even if they continue to use? Should they stay home when they drink or drug? Should they use only with friends? Should they take steps to make sure they cannot drive when they are “psychoactive” (pity poor Audrey Kishline Conn and her victims, killed when she drove drunk), or have sex only with reliable partners? These practical decisions need to be thought through with a trustworthy therapist who isn’t aghast at the idea of continued use by the client. If you, as a therapist, are incapable of dealing with clients on this basis, you are in the wrong business in the 21st Century.

  • Addiction and alcoholism are abstractions—problems are foremost.

The newest edition of DSM (5) does not use the terms alcoholism and addiction—except in regards to gambling! Rather than looking for what we regard as the classic symptoms of addiction (supposedly withdrawal and tolerance), DSM simply adds up the severity of problems due to use of a substance by the individual. This is a recognition that addiction is a variable syndrome and, by itself, is not the defining problem—the totality of consequences due to use are what concern us. And so, counselors, your job is not to ferret out admissions of addiction, but to identify the specific substance problems the individual has and to direct your attention to these.

Once again, I fear 12-step counselors are at a serious disadvantage, since they are taught that treatment revolves around such self-labeling.

  • Labeling/shaming is to be avoided at all costs!

Shaming people does not produce good results, and in fact exacerbates relapses.-Stanton Peele

It is not only that treatment should address problems. It is that clients regarding themselves primarily as an addict or alcoholic is, in and of itself, harmful to the individual. This act of labeling makes it less likely that they will achieve true recovery—or, indeed, even abstinence. What passes for treatment in the United States is often based on shaming (as in requiring people to list their sins and offenses, and then to seek God’s forgiveness). Shaming people does not produce good results, and in fact exacerbates relapses. Once again, traditional treatment adherents are pointed very much in the wrong direction.

  • Addressing life issues is essential in treatment.

The Substance Abuse and Mental Health Services Administration (SAMSHA) has redefined recovery as:

Recovery is a process of change whereby individuals work to improve their own health and wellness and to live a meaningful life in a community of their choice while striving to achieve their full potential.

SAMHSA builds recovery around four pillars: health, home, purpose, and community. All of these things can be related to substance use as both a cause and a result. But these aspects of people’s lives all have independent meaning and importance in treatment. To ignore them is to fail to provide adequate care.

  • Look beyond the walls of therapy, towards independence and empowerment.

…it is not adherence to treatment rules, customs, slogans, and precepts by which we judge a client’s progress.-Stanton Peele

Too often treatment is circumscribed within the four walls of the therapist’s office or therapy group (or church basement). But once we choose to focus on the individual’s entire life, we see that this can only be determined by behaviors far away from the treatment site, and going forward far beyond the treatment time frame. In other words, it is not adherence to treatment rules, customs, slogans, and precepts by which we judge a client’s progress. It is their ability to handle their own lives and to care for themselves. Producing such independence and empowerment is the ultimate measure of therapy’s success.

As we can see, all of these characteristics of good therapy require us to redirect conventional addiction and alcoholism treatment as practiced in the U.S. It is only by doing so that we can meet the challenges of the changing substance use world—changes that we are already confronting in Colorado and around the country.
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