Psychotherapeutic Approaches
Psychotherapeutic Approaches
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Counselor Beliefs and Behaviors
Clinician attitudes significantly influence the acceptance and utilization of new or innovative therapeutic approaches (Levenson, Speed, & Budman, 1995). In addictions treatment, this is influenced in part by clinicians’ understanding of addiction in general (Ogborne, Wild, Braun, & Newton-Taylor, 1998; Shaffer & Robbins, 1991), alcoholism in particular (Miller & Hester, 2003), and the purpose and intended outcome of treatment (e.g., abstinence; Caplehorn, Lumley, & Irwig, 1998).
Using cluster and discriminant analyses, Thombs and Osborn (2001) identified three distinct groups or types of chemical dependency counselors in Ohio (N = 343), based on participants’ views of addiction and its treatment. “Uniform counselors” (56%) appeared to lend moderate support for moral and disease concepts of addiction, “multiform counselors” (29%) endorsed a broad range of beliefs about the nature of addiction and its treatment, and “client-directed counselors” (15%) were characterized as practitioners who recognized “heterogeneity among clients and consider[ed] counselor listening to be an essential aspect of treatment” (p. 454). Compared to the multiform counselors, client-centered counselors, among other characteristics, had greater confidence in their knowledge of Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV; American Psychiatric Association, 1994) criteria, were more likely to hold a higher academic degree, and were more likely to be licensed as mental health counselors. This and other studies (e.g., Caplehorn et al., 1998; Moyers & Miller, 1993; Ogborne et al., 1998) suggests that addiction ideology (e.g., medical, humanitarian or empathic, moralistic) does affect the selection of treatment strategies.
Advances in medical technology have paved the way for more sophisticated research initiatives in the areas of human genetics, neurobiology, and behavior. Coherent synopses of these findings are available for professionals (e.g., W. R. Miller & Carroll, 2006) and laypersons alike (e.g., Interlandi, 2008), and have the potential to challenge longstanding and entrenched views of addiction, and drastically change how chemical dependence is treated.
Although W. R. Miller, Sorensen, Selzer, and Brigham (2006) noted a shift in how addiction is understood in the United States today, movement away from the “widespread” endorsement of substance dependence as a disease (Ogborne et al., 1998) to an understanding of addiction as a complex phenomenon is likely to be slow. This is true in light of the disease model’s history as the “dominant” model of addiction in the United States (Morgenstern, Frey, McCrady, Labouvie, & Neighbors, 1996). Definitions of addiction as a disease do vary (see Thombs, 2006), but common elements include an acceptance of addiction (namely alcoholism) as a chronic, progressive, involuntary, irreversible, and potentially fatal illness, which has as its core criteria the loss of control over the intake of alcohol and physiological dependence. A single, standard, pre-determined form of treatment is often used, without regard for individual differences among clients. Lifetime abstinence is the unquestionable goal, and participation in Alcoholics Anonymous (AA) is strongly endorsed.
Many chemical dependency counselors may thus practice within the bounds of one model of addiction—likely the (ill-defined) disease model of addiction. Such a myopic perspective can have the effect of missing, ignoring, or even dismissing other, perhaps equally valid, explanations for a client’s addiction and of an inability to appreciate or apply alternative treatment methods. Indeed, Tracy (2007) concluded her brief historical review of the disease concept in the United States by stating that “It may be time to embrace a more holistic view of disease and disability, to appreciate the multiplicity of factors … that affect what we consider ‘healthy’ and ‘diseased’” (p. 91).
This chapter is intended to offer practitioners an array or menu of treatment approaches in their efforts to assist a variety of clients struggling with substance use concerns. Just as there is no one “alcoholic” or “drug addict,” there is no one “tried and true” treatment approach. Miller and Hester’s (2003) “informed eclecticism” model guides the content of this chapter in that (a) there is no single superior approach to treatment for all individuals, (b) treatment programs and systems should be constructed with a variety of approaches that have been shown to be effective, and (c) different types of individuals respond best to different treatment approaches. In addition, W. R. Miller and Hester strongly emphasize tailoring or customizing treatment to the unique needs and strengths of each individual client, thereby increasing treatment effectiveness and efficiency. Implicit in this model is the need for all helping professionals in the addictions field to be familiar with a multiplicity of interventions so as to select from and offer the most appropriate type (or combination of types) and level of care to those needing and deserving quality services. Attention is given in this chapter to the application of research-supported counseling approaches. A list of useful Web sites addressing topics discussed in this chapter (namely, cognitive-behavioral interventions, brief interventions, solution-focused counseling, and harm reduction) is provided.
