It’s been almost 20 years since EJ Essic met Bobby, but she can picture it like it was yesterday.
Both were enrolled in a course on addictions at a technical college in North Carolina. Essic, who retired two years ago from her position as director of alcohol and drug services for the Bristol Bay Area Health Corp. in Alaska, was taking the course for continuing education credit for her counseling career. Bobby, a recovering alcoholic, was taking the class to learn more about the disease that had left an indelible mark on his life.
Bobby had been sober for 20 years by the time Essic met him. But recovery, Essic would learn, hadn’t been an easy road for him.
In treatment yet again after his 17th relapse, Bobby decided he couldn’t face any more failure and ran away. He shared with Essic that his intention had been to kill himself by jumping off a bridge. But before carrying out his plan, he called his wife. There, standing at the pay phone and preparing to say his final goodbye, Bobby told Essic that something clicked — he finally got it. He didn’t jump from the bridge. Instead, on his 18th attempt, Bobby finally succeeded in getting and remaining sober.
“I have never forgotten him telling that story,” says Essic, president of the International Association of Addictions and Offender Counselors, a division of the American Counseling Association. “I believe that was the point at which I really got the depth of the craziness of the disease itself.”
Bobby’s story taught Essic the lasting power of an addiction — about how many times it can pull a person back in, even after the individual has seemingly beaten the addiction. But it also taught her the power of the human spirit — that it’s never the right time to throw in the towel. “What it taught me was to never give up on anybody,” Essic says. “Never give up. You keep going back and plowing the ground. Each time, the person learns something. Nothing goes to waste. No matter how many times they have tried to get sober, until they are dead, there is a chance that we’re going to be able to make it.”
That lesson applies to more than just alcoholism, Essic says. “The common ground is the addictive process itself, which is inherently the same whether it is alcoholism, gambling, sex or whatever — the need to numb out, the denial of a problem, loss of control, the increased impairment of thought that helps to maintain the denial, the gradual losses that occur as the addiction becomes more severe and begins to affect and limit healthy physical, emotional, social and spiritual interactions. What do you do to numb the pain? Drink, gamble, whatever. How counseling helps is to be the compassionate voice of reality (and) offer support, encouragement, hope and a plan for change.”
Essic, who has a Ph.D. in counselor education and worked in private practice for almost 15 years, says addiction to alcohol separates people from the rest of their lives, both physically and emotionally. “It shuts you down and numbs you so that it becomes very difficult to have a real relationship because relationships are about intimacy and being able to emotionally feel an experience,” she explains. As people become less emotionally available, they also cut themselves off physically, missing the kids’ basketball games and plays, for example. “Alcohol becomes the primary relationship. It becomes the intimate partner. Everything else becomes secondary,” she says.
Among the factors most likely to increase an individual’s susceptibility to alcohol addiction is a history of addiction within the family, Essic says. But environmental factors can also have a strong influence. “I believe that trauma and grief are two of the major factors that lead many people into high-risk behaviors,” she says. “I don’t think anybody ever sets out to be an alcoholic. They learn that when they drink, they don’t have those feelings of emptiness and sadness.” But there is a biochemical mechanism that “flips,” Essic says. Part of the alcohol is converted to a substance that remains in the brain, she says, and after a certain point, the person needs the alcohol just to feel OK.
Oftentimes, people drink to numb themselves to their problems, Essic says, so one of the biggest hurdles to an addict’s sobriety is learning to deal with the remaining trauma, grief and pain in a healthy way. “When that pain is felt, a person who is addicted to alcohol has learned to effectively medicate that by drinking,” Essic says. “So they have to find a way to face that psychic pain without relying on the substance. That’s a huge challenge.”
Another challenge, she says, is finding a supportive atmosphere. If the addicted person is part of a family that drinks or doesn’t support the individual’s efforts to get clean, the likelihood of recovery decreases. A support group such as Alcoholics Anonymous is especially helpful in those circumstances, Essic says, because it validates the person’s struggle and need to be sober.
In addition to 12-step programs, Essic believes the keys to effective alcoholism treatment are education, cognitive therapy and grief counseling. Almost 20 years ago, Essic says, many counselors believed clients had to get sober first before delving into deeper topics with them. But that thinking has since changed, she says. “I believe you can’t not address those issues. Successful treatment is a combination of a lot of education about the disease, getting someone hooked up with good, solid, sober support and (helping) the person to acknowledge the grief, loss and trauma history and find ways to deal with it.”
In treating clients, counselors must grasp the true nature of the disease of alcoholism, Essic says. “You have to understand truly about addiction and the addictive process and how it operates on your brain because it’s completely irrational,” she says. “It’s very easy for novice counselors or people who do not understand the addictive process to fall back on either the belief that people should just be able to buck up and do it (kick the addiction), or they believe that it’s some sort of a moral flaw on the part of the person. And that is not true. The biochemical piece of this whole thing means that it’s not a moral thing, it’s not a willpower thing. I think the greatest challenge for people working with addiction is to keep the process of the addiction in mind and remember that this person is struggling.”
Another challenge for counselors is getting enough time with the client to truly help. Once a person has developed middle- to late-stage alcoholism, it can take as long as two years before brain function is back to what is considered normal, Essic says. Considering the session limits often imposed by health care, it can be a tall order to help the addicted client in such a brief period. When time is short, Essic says counselors often focus on educating clients about the disease and finding them a support system they can be part of as they recover.
Essic has treated addicted clients for many years, and she appreciates what they bring to the table. “I love working with alcoholics,” she says. “What I know from my own experience is that underneath all of that dysfunction and incredibly bad behavior are these people who, when they are sober, are really wonderful and are struggling to be alive.” She cautions other counselors to check their judgment of this population at the door. “Alcoholics can sense a judgmental person from 100 yards,” she says, “and if you are looking down on the client, if you think he or she is just a weak, horrible person, then that is going to block that client’s ability to be able to accept help from you.”
No silver bullet
Todd F. Lewis, immediate past president of IAAOC, works part time at the Presbyterian Counseling Center in Greensboro, N.C. The center is certified to administer Suboxone, a medication used to treat opiate addiction. “The research does suggest that medication is OK, but I don’t think it’s a silver bullet,” says Lewis, who counsels clients receiving Suboxone. He maintains that psychotherapy must be part of the treatment.
Cocaine and heroin are responsible for many addictions today, but Lewis adds that methamphetamine has been on the rise for the past few years. “Those are very serious addictions,” says Lewis, an associate professor in the Department of Counseling and Educational Development at the University of North Carolina at Greensboro. “Most of those drugs have a small therapeutic index. The difference between the effective dose and the lethal dose is really small. That can be a concern.”
Marijuana is another problem, Lewis says, especially with younger generations. Compounding the problem is a general feeling in today’s culture that marijuana is no big deal. “Surprisingly, marijuana can be quite dangerous,” he says. Although it doesn’t have the same overdose risk as other drugs, marijuana possesses carcinogens, and when combined with alcohol, the two increase each other’s effects, he explains.
Randy Haveson, executive director of the Higher Education Recovery Option (HERO) House in Kennesaw, Ga., and program director of the Collegiate Treatment Center at the Pat Moore Foundation in Costa Mesa, Calif., concurs. He works with recovering college students and says that parents who smoked marijuana when they were younger and thus think it’s no big deal today are misinformed. “Marijuana is such a different drug now than it was back then,” says Haveson, a member of ACA. Today’s marijuana is stronger, is more addictive and has more side effects, according to Haveson.
At the same time, he says, while an opiate addiction might cause a more severe withdrawal than an addiction to marijuana, opiates are water-soluble and therefore clear the system much faster than marijuana, a fat-soluble drug. Haveson says it takes up to six months for a daily marijuana user’s brain to go back to normal function after stopping.
For someone to develop a drug addiction, Lewis says two factors must be present: a biological factor predisposing a person to addiction and an environmental factor providing contact with the drug. Once an addiction develops, Lewis calls the potential fallout “tremendous.” From finances to relationships to employment to health, the associated problems can affect all aspects of an addict’s life.
The hurdles can be high for counselors treating drug addicts. “This is a population that often has a lot of defense mechanisms around their use (of drugs),” Lewis says. These can include denying or minimizing the problem and resisting treatment. The nature of the drug addiction and how it changes the brain creates a high likelihood of relapse, he adds, making it frustrating for those counselors trying to help. “As they say nowadays, relapse is the rule rather than the exception,” Lewis says. “If a counselor makes progress with a client and the client relapses, that is not only devastating for the client, but the counselor may become discouraged.”
Motivational interviewing, cognitive behavior therapy and strength-based approaches are among the treatments Lewis recommends for recovering drug addicts. “I think counselors can help by being empathetic, providing direct feedback, emphasizing clients’ choices and responsibility for their life and supporting positive changes they have already made,” he says. Lewis advises skipping the “old-school” methods of confrontation, because in his experience, harsh and argumentative tactics create resistance to change. “I am very careful to remain curious about my client’s life and experiences,” he says, “trying to convey that their experiences are their own and unique to them.”
Through a different lens
When Haveson of HERO House talks to recovering students, he doesn’t talk from a soapbox — he talks from experience.
Haveson was expelled twice from college because of poor grades. The reason he couldn’t get it together academically, he says, was because his addictions to drugs and alcohol were taking precedence. Upon receiving the letter from San Diego State University that he was being expelled for the second time, Haveson says he hit his lowest point. “My bottom was sitting on my bathroom floor with a knife, debating which wrist I was going to slit,” he remembers. Although Haveson wasn’t aware of the counseling resources on campus, he remembered having seen a telephone number on a billboard: 1-800-BE-SOBER. So he picked up the phone and called.
The woman who answered his call was a recovering addict, and Haveson credits her for saving his life. She convinced him that suicide wasn’t the answer and told him about a separate hotline for cocaine addicts, which Haveson also called. He got into a 12-step program and began seeing a counselor. After he got sober, Haveson went to the assistant dean at school and pleaded his case. He told her he was an addict but promised he was recovering and genuinely wanted another chance. “She said, ’OK, I’ll give you one more chance, but if you blow it this time, we have nothing more to discuss.’” Haveson didn’t blow it, and now he’s fighting to help other college kids get that same second chance.
“One of my frustrations has always been that on college campuses, we’re doing a lot of work on education and prevention but doing very little on treatment and recovery,” says Haveson, who earned a master’s in counseling from National University. “I’ve made it my life mission to make it easier for others to get help and support for their addiction issues and their recovery.”
A new study released by the National Institute on Alcohol Abuse and Alcoholism signals that binge drinking is on the rise among American college students. From 1998 to 2005, drinking-related accidental deaths among 18- to 24-year-olds rose from 1,440 to 1,825. The proportion of students who admitted to having recently binged on alcohol rose from 42 to 45 percent; those who admitted to drinking and driving rose from 26 to 29 percent.
Haveson, whose HERO House is opening a second location in Southern California this year, remembers how hard it was to try to get sober at college, regularly walking by the same bars and seeing friends who would ask him if he was going to one party or another. He wants to make the road to recovery a little less rocky for today’s college students. HERO House is a recovery house designed specifically for these students. Haveson and his team take recovering young people who want to go back to school but need a little extra support. HERO House enrolls them in two- or four-year colleges nearby, and the students stay at the house for one to two semesters on average to get back on their feet.
Most students come to HERO House with low self-esteem. Their addictions have impeded their ability to succeed at college, so they often believe they’re incapable of excelling. Haveson tells the young people that juggling an addiction and schoolwork is like walking around with a 50-pound backpack. “Once you get rid of that backpack, you find out how light you are and how much easier you can get things done,” he says.
The No. 1 addiction Haveson sees with college-age kids is alcohol, although many times, he says, it’s intertwined with other drug addictions. Marijuana ranks as the second most popular, he says, and opiates are also high on the list. Because alcohol is both socially acceptable and ingrained in our society, Haveson says many students feel as though they can’t have a normal college experience without it. But he assures his students that alcohol is just like any other addiction. “It’s just like changing seats on the Titanic,” he says. “Once you’re an addict, it doesn’t matter where you sit. The ship’s still going down.”
The normalization and acceptance of abusive drinking is a risk factor for addictions on campus, Haveson says. He points to professors going easier on students on Fridays because they know Thursdays are big drinking nights. Haveson has also noticed that addictions among students are starting earlier. “It used to be that people would come to college and develop their addictions there,” he says. But now, more and more kids are entering college with full-blown addictions. “If people come to campus with these problems already ingrained, then they can influence the others on campus,” he warns.
Key to effective treatment for college students is peer support, Haveson says. Traditional treatment centers aren’t heavily populated with other students, so a college student might enter rehab and have a 40-year-old businessman or a housewife as a roommate. “They just can’t relate at that same level,” Haveson says. HERO House, on the other hand, is students-only. “It’s people they can relate to,” he says. “It’s a peer-to-peer recovery model.” Haveson says more colleges and high schools are developing peer-support recovery networks. Rutgers University, for example, has on-campus recovery housing and support groups.
Many on-campus counseling centers are understaffed, Haveson says, and that means counselors who are overworked. That’s especially difficult considering how challenging college-age addicts can be. They might come in presenting with other issues or lie about their drug or alcohol use, Haveson cautions. “It takes so much time and energy to break through that.”
One of the best things counselors can do is educate themselves about substance issues and know when to refer clients if they can’t provide adequate help, Haveson says. “To thine own self be true. Know what your strengths are and work to your strengths.”
The female perspective
Jennifer Pepperell says women are another segment of society who could benefit from a different slant on addiction treatment. Pepperell, an assistant professor in the Minnesota State University, Mankato, Counseling and Student Personnel Department, says the counseling field should look at women more holistically than traditional treatment has done. Women are catching up to men in alcohol use, starting to exceed them in prescription drug use, and adolescent girls are starting to pass boys in cigarette use, according to Pepperell. Process addictions related to food, shopping and self-harming are also more prevalent among women.
Pepperell, who coauthored a book with Cynthia Briggs called Women, Girls and Addiction: Celebrating the Feminine in Counseling Treatment and Recovery, encourages counselors to look at what’s going on in the individual life of each female client, as well as how societal norms and messages have influenced her, to get a full picture of her addiction and its roots.
“Women are less likely to seek treatment,” says Pepperell, a member of ACA. They might fear that their children will be taken away, that they’ll go to jail or that they’ll be separated from friends and family, she says. “When they do seek treatment,” she continues, “a lot of times the treatment doesn’t seem to fit for them.” Although a traditional 12-step program works well for many, she contends it might not be as effective for some women. The first step of a 12-step program is to admit powerlessness over the substance. For women who feel powerless or oppressed, that might not resonate. “How can I admit I’m powerless when I don’t have any power to begin with?” Pepperell says. “Certainly this (model) does work for people, but there’s a large percentage of groups it doesn’t work for, and our treatment system is dominated by one model.”
Motivational interviewing is a good treatment method for addicted women, Pepperell says. It’s a supportive technique that works well with people who are in that early, indecisive stage of determining whether they even have a problem, she says, because it’s very open to taking clients right where they are at the moment. Motivational interviewing avoids confrontation and allows counselors to help clients build their motivation and confidence to change.
Harm reduction, as an alternative to abstinence treatment, works well also, Pepperell says, because it puts the responsibility and freedom to make the decision back on the client. Some of the principles behind harm reduction include providing nonjudgmental services, accepting that drug use is part of our world and working to minimize the effects of drug use instead of ignoring or condemning them.
Last, she recommends the use of feminist theory, where counseling comes from a model that looks at the woman’s perspective. Feminist theory encourages counselors to understand a client’s addiction alongside gender expectations, pressures from others and systemic pressures.
More than the name implies
One of Michael Barta’s current clients found her way to his office in a last-ditch attempt to save her marriage. The 30-something woman was caught cheating by her husband after multiple affairs. He gave her an ultimatum: Get help or he would leave. But when the woman began seeing Barta, a certified sex addiction therapist in Boulder, Colo., she still didn’t think she had a problem.
Barta, who holds a Ph.D. in counselor education from the University of Northern Colorado, eventually moved the client past her denial to see what was under the surface — a sex addiction. He helped her learn about the addiction, evaluate her acting-out behaviors, come to grips with her powerlessness over them and look at the consequences they were having on her and her family. Now in a 12-step program, she and Barta are delving into underlying issues, including a history of physical and sexual abuse. “She has really worked from going to treatment for (her husband) and to save the marriage to understanding that she has a problem,” Barta says. “She’s come out on the other side and doing it for herself.”
“Sex addiction has very little to do with sex,” Barta says. “It’s a way to cope, a way to soothe oneself, a way to escape. It’s similar to a substance addiction in that realm.” Unlike a substance addiction, however, where addicts get a high from an external substance (drugs, alcohol), sex addicts are addicted to a chemical produced in their own bodies. This is known as a process addiction. “But being addicted to our own body chemicals parallels other addictions because it’s progressive and we need more of the substance to feel the same,” Barta explains.
Family background and childhood experiences are often at the root of a sex addiction, Barta says. He points to a study done by Patrick Carnes, executive director of the Gentle Path program, which specializes in the treatment of sexual and addictive disorders for the Pine Grove Behavioral Center in Mississippi. Carnes’ study showed that 97 percent of people who have sex addictions report emotional abuse, 81 percent report sexual abuse and 72 percent report physical abuse. Sex and the mood-altering feeling it produces provides an escape.
Sex addiction is also about pseudo-intimacy, Barta says. Addicts are seeking intimacy, but they don’t want anyone to truly know them because they don’t believe anyone could love the “real” them. They use sex to prove they are lovable, Barta says, but without any accompanying intimacy, their needs go unmet and they reinforce their belief that they are unworthy because of their behavior. “It leaves them feeling even emptier than when they started,” he says.
According to Barta, a biological need to reproduce makes it impossible for the sex addict to abstain from sex completely in the same way that another addict might give up drugs or alcohol. “At our core, we’re sexual beings,” he says. “Biologically, that’s who we are. That’s a problem because you have to go from using sex addictively to starting and maintaining a healthy sexual lifestyle.”
In treatment, Barta uses a task-centered approach pioneered by Carnes. Among the 30 tasks are breaking through denial, understanding the addiction and formulating a plan to refrain from the addict’s acting-out behaviors, which might include anything from masturbating to visiting strip clubs to viewing Internet pornography. Barta also recommends his clients take part in a 12-step program to gain support. “When you walk into a meeting and there’s 50 or 60 people going through the same thing you are, you don’t feel so alone and isolated anymore,” he says.
Barta recommends that counselors educate themselves on sex addiction because not every addiction can be treated in the same way. And leave your judgment behind, he adds. “I compare (sex addiction) to alcoholism before AA because people thought it was a moral disease.” Barta disputes those who say that sex addiction is nothing more than an easy or even “cool” excuse for promiscuous behavior. “It is a real, verifiable, empirically researched condition that needs treatment,” he says, “and it takes a lot of courage to come out publicly.”
One for the money
Few places provide more enticing opportunities for someone addicted to gambling than Las Vegas. Larry Ashley, director of the Problem Gambling Treatment Program at the University of Nevada, Las Vegas, studies the addiction from ground zero.
Gambling often begins as a hobby, Ashley says, but the anxiety-relieving, excitement-creating escape from reality can alter brain chemistry and morph into an addiction. “Initially, it might be the excitement and feeling that they’re in control or they have the magic touch. It can be that adrenaline rush,” he says. But gambling can have an “amazing hold” on people, notes Ashley, an ACA member who has worked with clients who resorted to using a catheter at a slot machine so they wouldn’t have to leave to use the restroom. “Gambling can be like a drug,” he says, “and you can start on it for the same reasons.”
The root of gambling — money — makes it a particularly challenging addiction to fight, Ashley says. “You don’t have to have heroin or alcohol to survive, but you have to have money. That’s the trigger that sets it apart from the traditional drug and alcohol addictions.” A person needs money to survive, Ashley says, making it that much harder to separate the person from the money and, therefore, the addiction.
Relationships can take an especially big hit when there’s a gambling addiction. The addiction can even destroy marriages and families, says Ashley, giving the example of a child who thinks he is going to college only to find out that dad or mom gambled the savings away.
Much like counselors treating other addictions have found, Ashley says one hurdle to treatment is that society thinks gambling addiction is little more than a moral issue and that addicts should be able to “just say no.” But, Ashley says, because a process addiction such as gambling can change brain chemistry, it is similar to a drug.
Counselors treating gambling addicts should brush up on their financial counseling skills, says Ashley, who believes treatment should include credit and financial counseling. The challenge for counselors is that it’s rare to find academic counseling programs that teach about gambling addictions. “I would hazard to guess it’s on-the-job training,” says Ashley, who started the UNLV gambling treatment program in 2006.
Motivational interviewing is a good method of treatment with gambling addicts, says Ashley. He advises counselors not to waste time arguing with these clients because they can always come up with excuses and reasons not to do something. “The bottom line is that everything I do in treatment is based on where the client’s head is at instead of the old days, when we came in and thought we knew everything,” he says.
Ashley offers the example of a client who doesn’t think he has a problem. Instead of saying, “Yes, you do have a problem,” Ashley would ask the client to look at how his environment is talking to him. Perhaps the person has had run-ins with the law, doesn’t have any money or lost his job. If the client doesn’t like the consequences, Ashley would then ask him what control he has over changing his actions. Although Ashley supports 12-step programs such as Gamblers Anonymous, he doesn’t require clients to attend in order to receive treatment because he says many clients would simply refuse.
Counselors can best help these clients by giving them hope and showing them that it would be worthwhile to change, Ashley says. But counselors also need to do their own moral inventory, remaining mindful to be objective and not to look down on gambling addicts, he adds. “Don’t get that holier-than-thou attitude,” Ashley says. “These are not contagious decisions.”
Whether the client is a man or a woman, young or old, addicted to heroin or addicted to gambling, Essic says the lesson she learned from Bobby many years ago about never giving up is one from which every counselor can benefit. “It is essential that we understand that about all addictions,” she says. “The ’how’ is about faith and compassion. Our task as counselors is to hold the client accountable while remaining nonjudgmental. The client is responsible for his or her behaviors, but we have to remember that addictive thinking is impaired thinking, and our job is to help the client see reality and make good decisions. If we believe that a client cannot change, then we are not the counselor to be working with that client.”
Lynne Shallcross is a staff writer for Counseling Today. Contact her at firstname.lastname@example.org.
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