Looking at the Whole Person

When a person is involved in addiction it is not just their substance use that likely needs to be treated. Stopping the substance is usually just the first stage of the treatment plan. There is more to do after the "stopping". Not everyone realizes this. The other things to look at are what are the factors that led to the addiction in the first place. Historically there have been several different theories that have tried to explain the cause of addiction: the disease model, the moral model, the learned behaviour model, etc. These days the BioPsychoSocial-Spiritual Model (BPSS) is often used in treatment as it looks at all aspects of a person and incorporates some of the helpful aspects of previous models.

Sometimes it is the person's "biology" that is a significant contributing factor. For example, perhaps addiction runs in the family and thus they have inherited a genetic predisposition towards developing an addiction.  Other biological factors might be chronic pain or acquired brain injury.  Psychological factors might also be contributors. Perhaps there is an underlying mental illness or unresolved trauma. Perhaps there is low self-esteem. Social factors that might contribute are living in a culture which, like ours, has a liquor store every few blocks and where alcohol is a significant part of many occasions and celebrations. Also, some people come from families where substance use was a normal, daily happening. Even some workplaces and sports teams can exert an adult version of "peer pressure" where joining in the camaraderie of the beer at the end of the day, or after the game, is expected.     

Finally, we have the factor of spirituality. Spirituality in this sense does not necessarily mean religion although it may be religion for some. Overall, the factor of spirituality looks at meaning; purpose; or  a sense of connection with God, other people, nature or "something greater than oneself". Spirituality is very important to many in recovery to help alleviate the sense of emptiness that is often felt and to bring a sense of hope and peace.

The BPSS Model can be very helpful in guiding a person towards the areas they need to work on in their recovery. The paths people take to recovery may look very different depending on what factors are found to be contributing to each person's addiction. This is also referred to in the counselling field as a client-centered approach to treatment. The treatment plan will depend on what that particular client needs. What the client needs will be determined by the client, hopefully in collaboration with someone who has good knowledge of recovery such as a counsellor or other trusted mentor such as an AA sponsor.

Codependency

Codependency is a pattern of behaving that makes others more important than yourself. Sometimes people learn this pattern in childhood but sometimes they learn it later when in a relationship with an addicted person. It can also happen in relationships which are dysfunctional for other reasons such as violence or mental illness. In this post I will refer mostly to codependency in relation to addiction but many of the ideas are transferable to other situations also.

Codependency can be a very painful state and the codependent person often feels afraid and trapped. At the same time codependency can help one feel needed or in control of situations because they are functioning on the surface so much better than the addicted person. 

Codependent behaviours are generally broken down into three categories: caretaking, enabling and controlling. Caretaking refers to doing something for the other which they could do for themselves. Enabling refers to protecting the addicted person from the consequences of their actions. Finally, controlling behaviour shows itself in insistence that things are done a certain way. These categories can overlap sometimes but they provide a helpful framework.

People often ask what is the difference between caretaking and caring. A caring person might listen and show concern when they hear someone is losing their apartment due to unpaid rent. They might even drive someone to a few apartment viewing appointments. Caretaking would go much further. A caretaking person might take over the whole project of looking for the new apartment, looking on the internet, making viewing appointments, putting themselves on the lease, and organizing the move.

Enabling might show itself as continuing to lend money over and over to cover rent when the addicted person uses their own money on substances. While this may seem a nice and supportive gesture for the first or second time, when it happens over and over it just perpetuates the addicted person's problem.

People also wonder how to differentiate between controlling behaviour and setting boundaries. The difference here is largely in intention. A person who sets a boundary is trying to protect themselves. The person who is controlling is trying to make the other person do what they want.

Changing from codependent behaviour can be very difficult and anxiety-producing. However, continuing in codependency can become literally unhealthy for the codependent person. They can become ill themselves from worry, depression and many stress-related physical illnesses.

To change, the codependent person needs to start focussing on themselves more and on their own life. They need to learn about setting boundaries and saying no when it is better for them to do so. When the codependent person steps back it allows the addicted person to step up and determine what they want for their own life. Will they step up? That is the scary part. Mostly I think they will. A few don't seem to sometimes. The hard lesson that we all have to learn, is that we can't make someone else change. We can love and encourage and try to motivate, but in the end we can't follow them around 24 hours a day. They will be on their own at some point and will need to make the choice for themselves. In the meantime you must take care of yourself so you are not injured in the process.

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Boundaries

I think we all know what the word "boundary" means in general, but what does it mean when applied to a person? It means the "limits" of what one can allow for themselves.  It can refer to all aspects of a person...their body, thoughts, feelings, money, property, personal space etc. In working with people recovering from addiction, boundaries are a major topic and a major area requiring growth. We spend a lot of time on it.

The reason why so much time needs to be spent on boundaries is that when a person's boundary is "crossed" it can lead to all kinds of uncomfortable feelings. People might feel angry, hurt, resentful, pressured and more, when a boundary is crossed. Difficult feelings can be very big triggers for people to use their substance. Rather than feel the uncomfortable feelings they can easily turn to their substance for comfort.
 
Boundaries are tricky though. One interesting thing is that people often do not know that a boundary was crossed, they just know they feel "yucky". Initially it is often a backwards puzzle to figure out what boundary was crossed. The only clue might be that uncomfortable feeling.  

So, the first step in boundary work is identifying what your boundaries are. Are you okay with continuing to lend money to someone when they still haven't paid back the last loan? Are you okay with people being late and keeping you waiting? Are you okay with people dropping by your house unexpectedly? Are you okay with someone borrowing your car? Boundaries really vary from person to person. What is okay with one person may not be okay with another. Each person has to determine what is acceptable for themselves.

A huge part of boundary setting is having the ability to say "no".  for example, if someone asks you to do something that you don't want to do, are you able to say "no"? There may be times when you agree to do something you don't want to do and that can be fine. There may be good reasons to do it. However, if  you feel very angry and resentful about it then maybe you need to rethink it, maybe you should have said "no".

Saying "no" is one way of setting a boundary. Another way is to actually express what your boundary is, as others may be infringing without knowing it.  Expressing a boundary, or in other words setting a limit, with someone can feel very difficult. All kinds of fear and shame and other difficult feelings can arise. People fear their relationship might be damaged or that the person they are setting a limit with will be angry. Boundary setting often works out well. Many times people do understand and want to be respectful. Sometimes it doesn't though and you have an angry or hurt friend on your hands. Those are the times you have to remember that you are setting a boundary to protect yourself from potential relapse. When it comes to your  recovery you have to take very good care of yourself and hopefully the people in your life will understand.

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Addiction + Mental Health Disorder = Concurrent Disorder

You may have wondered what leads to addiction. There are many factors that might play a part but one factor is that some people have a mental health issue that they are "self-medicating" with a substance. It is very common that someone with depression, anxiety, bipolar, OCD  (and other mental health issues) might use a substance to try to help their symptoms. To some extent this initially works but then the original symptoms come back often worse than before. In addition, the repeated use of the substance that was initially meant to help, eventually brings along its own problems. 

The complicating factor in getting a mental health diagnosis is that substance use and withdrawal themselves often cause psychological symptoms like depression and anxiety. This means that initially it can be quite hard to figure out whether it is the substance use or an underlying mental health issue that is at play.  In early recovery and preferably once off the substances, some people are really helped by getting a mental health assessment and possibly medication or other treatment.

Medication can be very helpful but there are basic self-care strategies that are often also essential. For an anxious person, learning how to do mindfulness meditation or other "grounding" or relaxing practices is very important. Some do daily meditation or yoga but even going for a walk in the forest or watching a sunset can be helpful. Changing anxiety-increasing thoughts and self-talk is also very useful. Of course cutting down on caffeine and getting enough sleep and exercise will also help. Sometimes people tune out when they hear these last few points because we hear those things all the time for every health condition. However, I think that must mean they work. For more information on concurrent disorders please see the Center for Mental Health and Addiction.

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Slips and Relapse as Part of Recovery

Sometimes when I am in the hallways at work I am amazed how it can seem like "Old Home Week" or like a high school reunion. People are rushing around from group to their counselling appointment or outside for their afternoon break. So many people know each other and are happy to see each other knowing that they are back on track.

It is unfortunately quite common for people to slip or relapse while working on recovery. Not everyone does and it is certainly not a requirement but it does happen. The best one can do with this is to learn what went wrong and then specifically work on that trigger so it does not "take them out" again. The shorter a relapse (if it's only a day or so it is sometimes called a slip) the easier it is to get right back on track. When a real relapse does happen it can last for a month or two, or for many years.

Each attempt at recovery is not necessarily the same as the one before. Sometimes people find it much harder the second or third or fourth time around, but not always. The path to recovery is not necessarily a straight line and can be very unpredictable. Unfortunately some people actually die when they relapse. This can happen sometimes due to a change in tolerance for the drug, where they unintentionally overdose even though they used the same amount they used to use. This is tragic and so very hard to deal with.

Even though this may make us want to yell "Danger, danger" to the addicted people we know, fear is not always a good motivator. It is human nature to think, or at least strongly believe, that the worst will not happen to us. Instead success requires actually wanting to change ourselves. It is change of behaviour, change of thinking, change of how one handles emotions, that makes the difference to achieving a solid recovery. 

People go through stages of readiness to change. The Transtheoretical Model of Change is the model  we use to explain this. The six stages of change are pre-contemplation, contemplation, preparation, action, maintenance and termination. If someone has not even begun to think about whether they have an addiction or not, they are said to be pre-contemplative. If they are thinking about it but have not yet decided, then they are contemplative which also looks a lot like ambivalence. Once a decision to change has been made a person is said to be in preparation. This is the planning stage of how they will go about their change. Next people are in action when they are actually changing their behaviour. Finally maintenance is when the change is quite solid and is not so much active hard work anymore. Termination is when the change is "done" as in the smoker who is now at heart a non-smoker. In the world of alcohol and drugs many believe that termination is never reached, and that maintenance of  recovery is as good as one can do.  This might be true, as for many if not most, relapse is only a drink away no matter how much time has passed. It seems as if the addiction is only "asleep" rather than really gone.

The very good news is that there are people who succeed.There is a movement growing in the States where more and more, those who are successful in beating addiction are willing to let themselves be known openly.  I am excited about this trend and believe these brave people can offer so much inspiration and hope to those who are still stuck in the relapse/recovery cycle.

Source: Prochaska, J. O. & Di Clemente, C. C., (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research and Practice, 19(3), 276-288. Figure 2, p. 283

People, Places and Things

One of the most foundational ideas in working on one's recovery from addiction is to avoid the people, places and things that might "trigger" you or tempt you to use the substance you are trying not to use. For instance if your usual route home leads you by a liquor store it can be very helpful to find a different way home so you are not throwing temptation so directly in your way. Places to avoid are places where you used to use or that remind you of using.

People are sometimes the triggers and that can be quite hard to cope with, especially if they are friends or family. If possible it would be great if those friends or family would not use around you. That can mean a very different interaction but it can work well. Unfortunately sometimes friends and family have addictions of their own and they have trouble stopping for themselves let alone for you. There are a lot of people in recovery who have had to distance themselves from some of their friends or family in order to be "safe" from temptations to use.  This can definitely create some loneliness and is a good reason to get connected with non-using groups or people.

In most communities there are "twelve-step" groups like Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) and sometimes there are also groups like LifeRing and Smart Recovery. There are also often government programs dealing with addictions. All of these groups can enable people to get support and companionship in recovery. It really helps to feel like you are "not alone" on this journey.

Money can also really be a trigger for people. For some, availability of cash makes it very hard to resist spending it on the substance. Sometimes people buy grocery store or other gift cards so they know they will maintain some money for food and other necessities. The financial repercussions of addiction can be quite amazing. Some drugs are very expensive and it is more common than one might think for people to lose their homes, cars and other assets within only a couple of years.

Boredom is another tough trigger. Addiction is actually very time-consuming so without it people do not know what to do with their time.  All the time formerly spent getting, using and recovering from the substance is now freed up for other activities.  Probably less than half of the people I have worked with have former hobbies and interests that they can go back to. If they did play guitar or write or garden, they can try that again. For others it time to start experimenting with different activities and hobbies and trying to find things they like. Sometimes this is kind of fun but sometimes it is just necessary!

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Diary of an Addiction Counsellor

Many things come up in the day of an addictions counsellor. Sometimes the breadth of topics covered is hard to imagine. It can range from discussions about sleep and what time the client got up in the morning, to how to set a boundary with their spouse, to how to grieve the unexpected death of a friend, and that might take you to lunchtime. It is varied and often unpredictable but therefore also interesting.

I imagine that there are many people dealing with addictions and/or working on recovery who do not actually make it in to talk to a counsellor and maybe some of the topics covered here might be helpful. Sometimes I will write about relevant recovery topics and sometimes I will just write about my own thoughts on what I see and experience. Maybe other addiction counsellors will be able to relate.Maybe family members or loved ones of a person with addiction will find it interesting.

I think one of the major premises of recovery from addiction, and possibly any change, is that people do not change unless they are somehow motivated to do so. What makes one person motivated may not make any difference to another. Will a DUI do it or loss of a job or an ultimatum from a spouse. For some it is a health issue like liver disease or pancreatitis that finally hits home. I have often heard people say that they are no longer using to have fun but rather are only using to stop withdrawal. It is no longer fun for many by the time they make it in to the office.

Working with people in addiction and recovery can be very inspiring and real and even fun. There can be lots of laughter along with the tears. In my experience many clients are smart and attractive and most are very emotionally sensitive (although they may not realize it.) There are some days when what is happening seems so meaningful and essential that I think "Wow, what could be more important than this conversation with these people right now?"

In some ways having an addiction, if it leads a person to treatment, can be a blessing in disguise. That may seem an odd thing to say but for those who get a chance to really focus on themselves and their lives in counselling, the opportunity is there to learn and change and thereby avoid much future pain. Of course I am not recommending that addiction be the chosen way to begin the journey of personal growth and change, I am just saying that it can be.

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