By Britt Parramore LPC, CAADC
“Drug addiction/alcoholism, also known as substance dependence, is a chronic, relapsing disorder characterized by 1) compulsion to seek and take the drug, 2) loss of control in limiting intake, and 3) emergence of a negative emotional state (e.g., dysphoria, anxiety, irritability) when access to the drug is prevented.” (Galanter & Klebar 2008 pg. 3). Over the years, many different treatment methods have been implemented to treat what those in the medical community have labeled the “disease of addiction,” although; this disease model has recently been criticized by many in the treatment community. This rejection of the disease model stems from the fact that addiction can be eliminated from the life of anyone by choice, which raises the question if it is actually a disease at all. The importance of understanding this issue is of paramount importance in the field of counseling today because the problem is growing. Understanding the very nature of addiction is critical to formulating effective treatments. Treatments based on the disease model have a high rate of recidivism which has led many to look for alternate treatments, or those not based on the disease model of addiction. This paper will examine in three separate sections, three treatment methods for dealing with addiction. These three are: (1) Treatments based on the disease model, primarily the 12 step method. (2) Medical maintenance, particularly the use of Methadone to treat opiate addicted patients. (3) A faith based approach to treatment, specifically a Christ Centered Approach. An in depth evaluation will be given of all three methods with the goal of better understanding them in order to choose which is appropriate. Along with an examination, a compare and contrast will be used to better understand the differences in the three treatments to better understand their effectiveness.
This paper will also examine dual diagnosis, particularly those who have been diagnosed with both a substance use disorder and bipolar disorder. Research indicates a strong relationship between the two. When considering individuals with both disorders, it is important to consider an integrative approach to counseling. Integrative counseling involves merging two counseling theories into one in order to better help the client. This paper will suggest that those who have been diagnosed with both a substance use disorder and a bipolar disorder need both medical and faith based treatments. An argument will be made that faith based treatments are inadequate to address a medical issue such as bipolar and medical treatment is inadequate to address a spiritual issue such as substance abuse. The discussion of these treatments will build on the aforementioned examination of the three treatment models for addiction.
Relapse and relapse prevention are important to understand whenever discussing the treatment of substance abuse. Most addiction counselors will acknowledge that relapse is a part of recovery. This paper will correlate the different treatment models discussed with their influence on relapse and relapse prevention. Specifically, an argument will be made that the faith based approach lends itself to greater success in regards to relapse. The factors that determine this are spiritual, and are facilitated within the faith-based model. While it is true that the other two treatment methods discussed, 12 step, and medical model, do address the relapse problem, it will be argued that they are not as effective as the faith based approach. Relapse prevention is best fostered in an environment where the substance abuser makes a complete life outlook and worldview change. The change needed is best addressed within the faith-based system.
Many issues in the life of a person with a substance abuse problem arise due to their substance abuse. Among these issues, legal problems are paramount. Many who struggle with or have struggled with a substance abuse problem face many legal challenges. These sometimes include incarceration or the loss of basic legal rights such as the right to operate a motor vehicle. In an attempt to shed light on these issues, this paper will look at a study done of alcohol related deaths in amongst college students. This also brings up the issue of ethical responsibilities incumbent on substance abuse counselors. Specifically, counselors role in a method of legal reprimand used in American court systems today know as Drug Court. Counselors play a big role in the drug court system and there are ethical challenges that come along with this role. These two legal and ethical issues will be addressed in the same section.
There are many Biblical insights and issues that can be addressed when discussing substance abuse. Since a major focus of this paper will be an examination of faith based, Christ Centered substance abuse treatment, it’s important to understand the Biblical principles that form its foundation. The Bible has many things to say about how a believer should live; this includes insight into substance abuse treatment. These Biblical principles permeate all aspects of substance abuse treatment from the inpatient treatment center to after care and the prevention of relapse. In order to understand how Biblical principles affect substance abuse treatment, an understanding of how Christ Centered substance abuse programs work is important and will be discussed.
Finally, this paper will include my personal reflections on all the issues addressed. In order for me to adequately explain my views on these issues, I will need to give a brief testimony. I have experience in every topic discussed in this paper and can thus write from experience. I’ll base my reflection only on personal experience including Biblical principles I’ve personally applied with great success. I’ll also discuss my personal experience with regards to counseling those with substance abuse problems from all three treatment perspectives discussed. All my reflections will also be grounded in empirical evidence as much as that evidence is available.
12 Step Treatment Based On The Disease Model
Among the most popular treatment models based on the disease theory are the twelve step methods. These include Alcoholics Anonymous, Narcotics Anonymous, and Cocaine Anonymous. The twelve step method is the most widely used treatment philosophy for the treatment of both alcohol and drug addiction in the world today. “The model has a number of important therapeutic elements, including social support enhancement through group attendance, strategies for coping with dependence, and promoting the development of spirituality” (Emmelkamp & Vedel 2006 pg.104). Most of the work in the twelve step process is done in a group setting and individually with a sponsor. A sponsor is an individual chosen to help guide the addict through the twelve step process. The sponsor is almost always a recovering addict themselves usually with a year or more of sobriety under their belt. Sponsors are typically chosen out of the group meetings the addicted individual attends. Many times the recovery process for the addicted individual begins in an in-patient substance abuse rehabilitation program then continues after their release from the program in the community in which they live. Most communities in the United States have group meetings weekly associated with Alcoholics Anonymous that are open to the public. The predominant twelve step program in the world is Alcoholics Anonymous and its sister programs; Narcotics Anonymous and Cocaine Anonymous. While the 12 step method is considered a faith based method, there is no particular emphasis placed on anything specific. The 12thstep states “Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.” (AA Big Book, 2001 pg.59, 60). This spiritual awakening is based on submission to “the God of their own understanding.” This God can be anything animate or inanimate.
These steps are to be worked through one by one until completed. Upon completion steps 10, 11, and 12 are to be practiced on a daily bases. Alcoholics Anonymous’ stance is that these steps are not a cure to addiction nor is there any cure, but only a daily reprieve if the steps are worked properly and meetings attended regularly for life.
Although the 12 step method of treatment is the most widely used in the world today, there is little empirically supported evidence that supports this method over others. In fact, “despite decades of dominance of approaches based on 12-step principles, there have been no rigorously controlled research design comparing 12-step treatment outcomes to no-treatment controls, and a recent review found no gains in outcomes for 12-step interventions over alternative interventions” (Miller, 2007, p. 568). Considering the scope and size of the substance abuse problem worldwide, it is important for counselors to understand the lack of evidence to support using 12-step methods. It’s even more important for counselors to understand that the 12 step method may in fact be not only unsuccessful, but harmful. A recent study done in Virginia showed the success of 12-step programs, at 0%-15%, was no more effective than the substance abuser receiving no treatment at all (Miller, 2007). In regards to 12-step treatment programs Miller writes based on his study; “the result that treatment programs infused with 12-step principles appear at best ineffective, and possibly harmful as interventions based on the counter-therapeutic nature of key elements of the 12-step approach” (2007, p. 573). Miller theorizes the reason for this ineffectiveness and possible harm is due to the precepts of the disease model. His view, based on his research, is that the disease concept takes the responsibility for harmful behaviors away from to substance abuser and places it on the disease (2007). One common response used by participants in 12-step programs is; “I’m not a bad person trying to be good; I’m a sick person trying to get well.” Or another response may be; “it wasn’t me, it was the disease.” Along with the blame shifting, the 12-step approach also instills a sense of powerlessness into the individual. They are told their addiction is permanent and can only be managed daily by attending meetings and working the steps. This also places all responsibility to change on the external factors of attending the meetings and working the steps.
Medical Approach To Treatment
The medical detoxification and stabilization approach to rehabilitation involves using drugs to take the place of, or diminish the desire for the addictive substance the patient is seeking treatment for. This type of treatment is usually for people who are experiencing withdrawal symptoms or significant emotional instability after a period of prolonged use of drugs. (Galanter & Klebar 2008). Most people suffering withdrawal symptoms significant enough to warrant medical detoxification are usually addicted to opiates, opioids, alcohol, or Benzodiazapams. One drug that began to be widely used in the 1970’s for the treatment of heroine addiction (an opiate drug) and has continued to this day is methadone. “Methadone has been used effectively as a maintenance medication because of its oral administration, slow onset of action, and long half life. Thirty years of study on the effectiveness of methadone reliably report major reductions in opiate use, crime, and the spread of infectious diseases associated with heroin dependence.” (Galanter & Klebar 2008 ch.7). Methadone works by fulfilling the craving an individual has for heroine, and by giving them a reprieve for up to 24 hours from withdrawal. The down side however is, methadone is actually more addictive than the heroine the person is trying to quite. So in essence it is simply swapping one addictive drug for a more addictive drug. Methadone is administered through clinics where the patient must show up on a daily basis to receive their dose for that day. If the patient misses one day, withdrawal symptoms soon set in and last until the next dose of methadone can be administered. For this reason the methadone patient is in essence a prisoner to the methadone clinic. Withdrawal symptoms from methadone are extremely severe and can lead to death in extreme cases. Actually the withdrawal symptoms from methadone are much more severe that the withdrawal symptoms of heroine it is replacing and last much longer.
Faith Based, Christ Centered Approach
The last of the treatment methods discussed here is the faith based approach, particularly the Christ centered approach. This method uses the truth of God’s word to address not the “disease” of addiction, but the problem of sin out of which addiction comes. One of the proposed reasons for the success of faith based programs is their incorporation of personal disciple into the treatment program (Neff, Shorkey, Windsor, 2006). Faith based programs teach that the struggling individual does not have an addiction problem but a sin problem and addiction is a symptom of that problem. Most faith based programs are inpatient and can last from 30 days up to 2 years depending on the program. Most programs are staffed by Christian counselors and pastors who many times live at the center with the clients. Most of the actual addiction treatment comes in the form of teaching from the Bible, particularly life applicable truths that deal with overcoming sin. The first goal of the program is always to determine weather or not the client is a born again Christ follower and if not work begins to reach that goal. Most programs use a curriculum that lays a foundation of basic biblical truths and then builds on that foundation through teaching and counseling. Most programs are associated with a local church that in many cases financially supports the program. Clients usually attend that church three times a week and in many cases volunteer at the church while in the program. Counseling in Christ centered programs usually revolves around forgiveness. A recent study found that spirituality in conjunction with the notion of forgiveness may facilitate in the prevention of substance abuse (Lyons, Deane, Kelly, 2010). First the client must accept the forgiveness offered by salvation and then they work on forgiving anyone with whom they may have been harmed by. Through this forgiveness and by implementing biblical principles in their life the client can live a life free from the control of drugs or alcohol. The entire basis of this treatment approach is built on the addicted individual taking responsibility for their own actions, admitting they were entirely responsible, turning to Jesus for forgiveness, and then living daily in obedience to biblical principles which facilitates lifelong sobriety. This is made possible only with God’s help and daily guidance. An interesting study done by Mason, Deane, Kelly, and Crowe concluded that a definite correlation can be made between spirituality and reduction of cravings (2009).
Dual Diagnosis, Bipolar and Substance Abuse
While an argument can be made that faith based programs are the most effective for the treatment of substance abuse problems, there is less evidence to support their effectiveness to treat other conditions such as bipolar disorder. “Bipolar disorder and substance-use disorders commonly occur in the same individual. In fact, “bipolar disorder has a higher prevalence of substance-abuse disorders than any other psychiatric illness” (Swann, 2010, p. 276). Not only are the instances of bipolar disorder more common among substance abusers, the severity of the disorder is worse (Swann, 2010). Given that bipolar disorder is a brain chemical disorder, medication is often needed.
One weakness of some faith based programs is there hesitance to use medication in the treatment of psychological disorders. In patients with this dual diagnosis, an integrative approach is more beneficial. An integrative approach utilizes both medicine and biblical counseling. A dually diagnosed patient receiving substance abuse treatment from an integrative counseling center is benefited by their use of medication to treat the bipolar disorder while at the same time biblical counseling to treat the substance use disorder.
Relapse And Relapse Prevention
“Relapse is a characteristic of all behavioral disorders and, unfortunately, the prevalence of relapse is quite high for most of them” (Brandon, Vidrine, Litvin, 2007, p. 257). Interestingly this article from the Annual Review of Clinical Psychologyrefers substance use disorders as behavioral disorders. Like all behavior disorders, the possibility of relapse is, as suggested, high. Prevention of relapse begins in treatment. The foundation built in treatment should be the support needed to prevent relapse. The 12 step method of treatment built on the disease model teaches their clients that being cured is impossible. It also teaches, as mentioned above, that addiction is not the fault of the client but the fault of the disease. Just like an asthma sufferer having an asthma attack, relapse, in the disease model way of thinking, is a symptom of the disease and should be expected. This takes responsibility away from the substance abuser and leads to a high rate of failure. It can’t really be said that the medical model reduces relapse since the client never stops using drugs, they just swap their drug to one prescribed by a doctor.
The Christ centered approach, on the other hand, teach their clients, that they are responsible for their actions and relapse is not ok. More importantly however, the Christ centered approach, gives the client a new way to live daily complete with supernatural help to do so.
Legal And Ethical Issues
“Among college students ages 18–24 from 1998–2001, alcohol-related unintentional injury deaths increased from nearly 1600 to more than 1700, an increase of 6%” (Heeren, Wechsler, 2005, p. 259). College age drinking has become a major problem in the United States today which is causing many legal problems for those involved. Particularly, many college young adults are being arrested and charged with driving under the influence or DUI. Even more troubling are the convictions for manslaughter being handed down to college age students who are involved in alcohol related deaths. The statistic above proves the problem is only worsening. Substance abuse counselors are challenged today as never before to implement effective treatments especially with college aged substance abusers. The sooner effective treatment can be implemented the less chance the college age person has of becoming a statistic. It is an ethical responsibility for counselors to be trained properly to deal with substance use problems and be informed about the most effective treatments. Considering the study this paper cited on the harm of 12 step programs, a serious look should be taken as to whether or not these type programs should ever be used in counseling.
“Since their inception in the late 1980s, drug courts have become the most prevalent specialty court in the United States” (DeMatteo, Filone, LaDuke, 2011, p. 806). Another legal and ethical issue facing counselors today is the prevalence of drug court to deal with alcohol and drug related offences. Drug courts are set up to give individuals who have been convicted of an alcohol or drug offense a chance to have their charges dropped by maintaining prolonged sobriety. Most drug courts assign a counselor to each participant. The counselor, in most instances, formulates a plan of recovery for the participant. This plan usually involves either in-patient treatment or intensive out-patient treatment. Also, the participant is usually subjected to weekly drug screening to make sure they are staying clean. If a participant cooperates with the counselor and the court, passes all their drug screens, and pays a fine, their legal charges are dropped, thus giving them a clean slate to work with.
Biblical Values And Insights
It may surprise many to know that drug addiction is actually mentioned in the bible. The Greek word pharmakia is used in Galatians 5:20. This is the root of the English word pharmacy. Most modern English translations have translated this word as either sorcery or witchcraft. There are a couple of views as to why the word is mistranslated, but those are beyond the scope of this paper. What is important to know is that Paul was referring to an intoxicating substance other than alcohol. Actually, one verse later, Paul mentions drunkenness. These two words are used to describe two “lust of the flesh,” or more simply, things people indulge in because they feel good. Paul does not refer to these at any time in the bible as diseases. This is vitally important when discussing effective substance abuse treatment methods. A biblical approach to treatment, called faith based in this paper, teaches individuals struggling with substance abuse that they, along with God’s help, can control abusing substances. Lust of the flesh, as Paul suggest, are sin. Therefore, drug use and drunkenness are sins, no more, no less. The answer to sin is Jesus. Jesus said one of His purposes for His followers is for them to live in freedom. Without Jesus, there is no access to this freedom. The faith based approach discussed in this paper is effective because it has Jesus as its foundation. Jesus also suggested His followers to follow Him daily. This means obedience. Another reason the faith based approach is successful is it gives individuals a new way of life. All their effort is spent following Jesus, not trying to avoid relapse. This is effective and gives the former substance abuser a new life free from drugs or alcohol, free to follow Jesus.
There is a difference between empathy and sympathy. Empathy comes from having personally experienced something and relating to someone else based on that. I have struggled with a substance abuse problem and have been freed from it. I now help others struggling with substance abuse. My life as a substance abuser lasted about 10 years before I sought help. At first, I went to a 12 step based in patient facility. It was probably the most depressing period of my life. It was only after I learned of studies, such as the one in this paper, that proved how harmful disease model based programs can be that I realized why it was so ineffective and miserable for me. They told me I was hopelessly addicted and could never escape it but if I went to meetings and followed their book I may have a daily reprieve. They also told me none of it was my fault and if I relapsed that wouldn’t be either. Well, I relapsed and I blamed it on my disease. This went on for about a year and I was at the end of my rope. A friend told me about a different type of treatment, one that used the bible and Godly principles. I entered that program and eventually committed to serve Jesus the rest of my life.
For the past 3 years, I’ve been serving as a substance abuse counselor in an integrative program and a strictly Christ centered program. I love doing this. I love seeing people who have lost hope come to the realization that they indeed do not have a disease and that there is hope. I’ve seen a lot of success. In fact as I write this paper, I’m thinking about the speaking engagement I have tonight at a Christ centered program. I’m going to tell them the same things I’ve just written in this paper, that hope is available.
I’ve learned much in the Counseling program here. I plan on taking what I’ve learned and implementing it as an Integrative Substance Abuse Counselor. Clinical Psychology has so much to offer in the treatment of substance use disorders. My plans are to couple that with what I know about biblical counseling to give me a truly integrative model.
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