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| The Historical Essence of Addiction Counseling | |
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| William L. White, M.A. | |
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| What distinguishes the profession of addiction counseling from the array of helping roles that have preceded and have followed it? What would be lost if the specialized knowledge and functions performed by the addiction counselor disappeared? This essay will explore these questions by attempting to define the historical essence of addiction counseling. The distinctiveness of this role lies in the unique way alcohol and other drug (AOD) problems and their solutions have been defined within the addictions field. It also lies in nuanced views of the addiction counselor's relationship to self and his or her relationship to the addicted client family, other service professionals and the community. | |
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| Theoretical Foundation | |
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| There are four defining premises of addiction counseling that historically separate the addiction counselor from other helping roles. These premises are that: | |
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| 1) severe and persistent alcohol and other drug problems constitute a primary disorder rather than a superficial symptom of underlying problems | |
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| 2) the multiple life problems experienced by AOD-impacted individuals can be resolved only within the framework of recovery initiation and maintenance | |
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| 3) many individuals with high problem complexity (biological vulnerability, high severity, co-morbidity) and low 'recovery capital' (internal assets, family and social support) are unable to achieve stable recovery without professional assistance, and | |
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| 4) professional assistance is best provided by individuals with special knowledge and expertise in facilitating the physical, psychological, socio-cultural and often spiritual journey from addiction to recovery. | |
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| If AOD problems could be solved by physically unraveling the person-drug relationship, only physicians and nurses trained in the mechanics of detoxification would be needed to address these problems. If AOD problems were simply a symptom of untreated psychiatric illness, more psychiatrists, not addiction counselors would be needed. If these problems were only a reflection of grief, trauma, family disturbance, economic distress, or cultural oppression, we would need psychologists, social workers, vocational counselors, and social activists rather than addiction counselors. Historically, other professions conveyed to the addict that other problems were the source of addiction and their resolution was the pathway to recovery. Addiction counseling was built on the failure of this premise. The addiction counselor offered a distinctly different view: 'All that you have been and will be flows from the problem of addiction and how you respond or fail to respond to it.' | |
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| Addiction counseling as a profession rests on the proposition that AOD problems reach a point of self-contained independence from their initiating roots and that direct knowledge of addiction, its specialized treatment and the processes of long-term recovery provide the most viable instrument for healing and wholeness. If these core understandings are ever lost, the essence of addiction counseling will have died even if the title and its institutional trappings survive. We must be cautious in our emulation of other helping professions. We must not forget that the failure of these professions to adequately understand and treat addiction constituted the germinating soil of addiction counseling as a specialized profession. | |
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| Use of Self | |
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| Virtually all of the helping professions speak of the 'use of self' in the helping process, but addiction counseling brought many unique dimensions to this process. First, the addictions field is the source of the very concept of 'wounded healer'—the idea that experiencing and overcoming an affliction bestows certain powers to understand and heal others similarly afflicted (White, 2000). The wounded healer tradition in addiction counseling begins with the abstinence-based, Native American cultural and religious revitalization movements of the 18th century, spans the 19th century recovery activists (e.g., Washingtonian and Reform Club missionaries) and early 20th century lay alcoholism therapists, and re-emerges in the modern addiction counselor. Perhaps more than any other therapy discipline, addiction counseling has respected the notion of 'calling' in the choice of this profession. | |
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| The profession of addiction counseling has not made the experience of addiction and recovery a required ticket of entrance, but it has called for a greater level of experiential authenticity than that found in allied counseling professions. Ernie Kurtz alluded to this when he spoke of the shared characteristics of those not in recovery who made great contributions to the modern alcoholism recovery movement: 'They were not alcoholic, but they did have something in common: each, in his or her own way, . . . had been emptied out. . . . Each had encountered and survived tragedy' (Kurtz, 1996). | |
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| The calling and commitment that has historically characterized addiction counseling is reflected in the relationship between the counselor and client. What the addiction counselor brings in addition to their skills is their whole person—their life. This is reflected in a less hierarchical relationship and a higher level of self-disclosure than is found in allied helping professions. Courtenay Baylor, the first (1913) recovered alcoholic to work as a professionally paid lay alcoholism therapist, went so far as to negotiate a reciprocal agreement of confidentiality with his clients. This greater emphasis on mutual vulnerability, mutual self-disclosure and mutual honesty (more directly expressed) reflects a greater use of self in addiction counseling. At the same time, the counselor has been admonished to separate his or her own experience from the client's recovery processes—a paradoxical demand for personal involvement and detachment not seen in allied professions that place greater emphasis on therapeutic distance and objectivity. | |
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| Providing hope is a crucial dimension of all helping professions, but unique among these professions is the addiction counselors' role in offering themselves as 'living proof' of such hope. The addiction counselor's responsibilities historically have included providing the evidence of the potential for long term recovery through their own personal family story or by guiding the client's exposure to a vibrant community of recovering people. | |
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| Another unique quality of the addiction counselor is the capacity to absorb losses and use such losses as rituals of rededication. The high mortality rate of alcoholics and addicts means that addiction counselors experience many losses, some of them quite horrific. To sustain oneself in the face of such losses requires the ability to use these experiences to deepen one's understanding of the nature of addiction and to recommit oneself to finding new ways to reach those who have not yet achieved stable recovery. To fail to master this ability is to open oneself up to emotional injury and the protective detachment or over-involvement that such injury can spawn. Seasoned addiction counselors are acutely aware that they are involved with their clients in a life or death struggle for recovery. The stakes involved in this work are very high and that awareness brings its own burdens and rewards. | |
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| Relationship with Clients | |
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| The first requirement for successful counseling of the alcoholic is the correct attitude. . . . If you don't have this, then it doesn't matter how many techniques you use, they aren't going to work. —Marty Mann, 1966 | |
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| Contempt, often mutual, is an enduring and often troubling theme in the historical relationship between helping professionals and addicts. . . . What recovered people brought to this field [addiction counseling] was, first and foremost, the capacity for moral equality and emotional authenticity. —Author, 1998. | |
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| One could argue that a specialized addiction field was born out of the contempt in which alcoholics and addicts where held by other helping professions. Whatever technical skill the addiction counselor may possess that is lacking in these other professions, that skill may not be as important as the addiction counselor's ability to transcend this history of contempt. When one spends time with the pioneers of modern addiction counseling (e.g., Mel Schulstad), one is struck by the deep acceptance and affection that marks their relationships with people seeking to escape addiction to alcohol and other drugs. It is not that they fail to see the crude veneer that addiction has wrought; it is that they are able to see the person masked by this characterological armor. Alcoholics and addicts have not fared well in service relationships in which they sense an air of moral superiority. What the role of addiction counselor brought, at its best, was a capacity for acceptance and a willingness for being with, rather than doing to or for. This kind of empathic identification and alliance is important in all helping professions, but the character excesses and shenanigans of the addicted render them less lovable and more easily extruded from traditional service systems. | |
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| What the addiction counselor knows that other service professionals do not is the very soul of the addicted—their terrifying fear of insanity, the shame of their wretchedness, their guilt over drug-induced sins of omission and commission, their desperate struggle to sustain their personhood, their need to avoid the psychological and social taint of addiction, and their hypervigilant search for the slightest trace of condescension, contempt or hostility in the posture, eyes or voice of the professed helper. | |
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| The relationships between the addiction counselor and his her clients have much in common with other therapeutic disciplines, but there are qualitative differences. Addiction counseling has had a greater respect for the power of unseen forces in the recovery process, particularly processes of sudden, transformative change (see Miller & C'de Baca, 2001). The field has also had a sustained interest in stages of change processes (see Wallace, 1974). Studies of addiction have generated the models of change that are now being applied to many other problems (Prochaska, DiClimente, & Norcross, 1992). One also finds interesting areas of emphasis in the addiction treatment world that are less visible in other disciplines, e.g., the value of catalytic, sense-making metaphors; the importance of narrative reconstruction of personal identity and interpersonal relationships (via story reformulation and storytelling); positive and culturally-nuanced reframing of abstinence; and a deep appreciation for paradox (e.g., strength coming out of weakness, winning by admitting defeat). | |
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| Like other counseling-based professions, addiction counselors have long been preoccupied with the mastery of clinical technique and have tried, since Peabody's 1931 The Common Sense of Drinking, to manualize the process of addiction counseling so that the skillful execution of clinical procedures could be passed on to others. Addiction counselors have also, perhaps more than any other therapy-based discipline, believed that their clients could be formally educated to self-manage their own recoveries. There is a long history of the use of bibliotherapy in addiction counseling, and giving lectures to clients about addiction and recovery dates to the 19th-century inebriate homes and asylums. It was Ray McCarthy at the Yale Center of Alcohol Studies who in the 1940s rebirthed the modern use of group lectures as a therapeutic tool in addiction counseling (McCarthy, 1946). Casting service consumers in the role of 'students' rather than 'patients' is a unique thread within the history of addiction counseling. | |
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| If there is a therapeutic stance most unique to addiction counseling, it is perhaps the virtue of humility. Alcoholics and addicts have long possessed ingenious ways of instilling such humility in therapists who saw themselves in control of the therapeutic process. While seasoned addiction counselors muster the best science-based interventions, they do so with an awareness that recovery often comes from forces and relationships outside the client and outside the therapeutic relationship. It is in this perspective that the addiction counselor sees himself or herself as much a witness of this recovery process as its facilitator. In the end, the job of the addictions counselor is to find resources within and beyond the client (and the counselor) that can tip the scales from addiction to recovery. To witness (and be present within) that process of transformation is the most sacred thing in the field, and what would most need to be rediscovered if the field collapsed today. | |
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| The history of addiction counseling can be divided into two eras: the discovery of commonalities and the discovery of differences. In the first era, the field catalogued what people with alcohol and drug problems shared in common and through that process defined addiction and its diagnostic criteria. The common needs and change processes of people seeking to resolve these problems further led to clinical protocol that addressed these common needs and facilitated those change processes. The second era was marked by the recognition of differences—different patterns of AOD use, different etiological pathways to problem development, differential responses to treatment interventions, and multiple long-term pathways and styles of recovery. We are today in transition from herding clients through 'programs' to the recognition of 'special populations' (demographic, cultural, and clinical subpopulations) to the development of highly individualized approaches to clients within these subpopulations. The essence of addiction counseling is to recognize the shared needs a client may experience based on his or her gender, developmental age, culture, sexual orientation, drug choice, psychiatric diagnosis, living environment (urban, suburban, rural), and religious orientation, but to not entrap and lose the client's individuality within these categories. When you strip away the theory and the technique, the procedures and the paper, addiction counseling remains a unique interpersonal encounter. | |
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| In addition to a theoretical foundation and a body of technical cultural knowledge and skill, helping professions are distinguished by fiduciary relationships with their clients that are guided by a set of ethical principles and guidelines. Such ethical sensitivities and standards in addiction counseling have a very short history (perhaps dating from the 1987 publication of Bissell and Royce's Ethics for Addiction Professionals) and have borrowed heavily from the disciplines of psychiatry, psychology and social work. It is only recently that the field has begun to refine its ethical codes to reflect the unique vulnerabilities of its clients, service providers and service institutions. What the field has recognized is its power to do harm in the name of good, and it is that awareness that is driving the heightened emphasis on ethical decision-making in addiction counseling. | |
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| Relationship with Other Professionals | |
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| On the road from 'paraprofessional' to professional, addiction counselors entered into partnership with other service professionals to create multidisciplinary service teams. The model for such collaboration was set by Francis Chambers, a Peabody-trained lay therapist, who was the first addiction counselor to work within a multidisciplinary alcoholism treatment team. In 1935, Chambers began a sustained collaboration with prominent psychiatrist, Dr. Edward Strecker, at the Institute of the Pennsylvania Hospital in Philadelphia (Strecker & Chambers, 1938). Since that time, lay therapists and then alcoholism addiction counselors have found ways to replicate Chambers' model of collaboration. The best of these collaborations have been based on mutual respect and a commitment that each member of the multidisciplinary team would practice within, and only within, the boundaries of his or her education, training, and experience. | |
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| Chambers and other early twentieth-century lay therapist also pioneered a unique pattern of intraprofessional collaboration. Mentoring other lay therapists (e.g., recruiting and training former clients with aspirations and aptitude for such a role) was an essential part of each lay therapists responsibilities. That tradition declared that one's professional career responsibilities had not ended until new people were mentored to fill the space created by one's impending absence. Given the aging of addiction counselors and others working in the addictions field, we would do well to re-emulate that tradition. | |
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| Relationship to Community | |
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| If there is an individual who most represents the addiction counselor's understanding of the power of community in the recovery process, it is Matt Rose. Rose pioneered a community development model of alcoholism counseling within the anti-poverty programs of the 1960s and was in 1972 one of the founding members and first director of the National Association of Alcoholism Counselors and Trainers (NAACT)—NAADAC's precursor. What Rose understood, perhaps more than anyone before or after him, was the importance of anchoring and strengthening recovery within the context of a larger community of recovering people. For Rose, recovery, to be sustainable, had to be nested within the natural environments in which people lived out their lives. His focus was not on building treatment institutions, but on building and expanding cultures of recovery within the very fabric of local communities. He believed there was a hidden reservoir of recovery support in the larger community that could be tapped to spark and sustain the recoveries of those seeking help. In his view, the alcoholism counselor was more a guide into this community relationship than a traditionally defined therapist. What the addiction counselor, at his or her best, contributes that is lacking in other human service disciplines is a detailed knowledge of local cultures of addiction and cultures of recovery. That knowledge is crucial in facilitating clients' journeys between two psychological and social worlds. | |
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| There is also a lost dimension of activism within the role of addiction counselor. Historically, that activism confronted AOD promotional forces that targeted vulnerable populations (e.g., AOD advertising aimed at adolescents), mobilized support for local continua of addiction treatment services, and helped organize peer-based recovery support services and recovery support groups (e.g., recovery homes, recovery training and work projects, alumni support groups). In the wake of the recent restigmatization, demedicalization and recriminalization of addiction, counselors are re-involving themselves in recovery advocacy organizations to counter the effects of such stigma on yesterday, today, and tomorrow's clients. | |
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| Pace Yourself: It's a Marathon | |
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| One must +be careful in carrying light to the community to not leave one's own home in darkness. —Advice from a wise father on his son's decision to pursue a career in addiction counseling | |
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| The final thing that addiction counselors brought to the professional table was an ability to sustain themselves over time working with alcoholics and addicts and their families. That capacity for survival and health in the face of constant confrontations with trauma and pain is noteworthy. I have been writing for more than two decades about what it takes to sustain oneself in this most unusual of occupations, and my answers to that question have changed little. The four things that mark the essence of daily life in recovery are also the sources of sustenance for the best addiction counselors. These core activities include 1) centering rituals (acts of prayer, meditation, self-reflection) that help keep one's 'eyes on the prize,' 2) mirroring rituals (reaching out to kindred spirits for support and inspiration), 3) acts of self-care (taking care of oneself and one's intimate circle physically, emotionally and spiritually), and | |
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| 4) unpaid acts of service (reaching out to others outside the context of our professional duties in ways that elevate our spirits). | |
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| There is an inevitable process of homogenization of human service roles. What has distinguished addiction counselors from other service professionals is worth cherishing and protecting. | |
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| William L. White is a Senior Research Consultant at Chestnut Health Systems and the author of Slaying the Dragon: The History of Addiction Treatment and Recovery in America. | |
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| References | |
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| Remaking a Man; One Successful Method of Mental Refitting. New York: Moffat, Yard & Company | |
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| Ethics for Addiction Professionals. Center City, MN: Hazelden | |
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| Spirituality and recovery: The historical journey. The Blue Book 47, 5–29 | |
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| Counseling the alcoholic. The Blue Book 43 (http: www.nccatoday.org a-mann1.html) | |
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| A public clinic approach to certain aspects related to alcoholism. Quarterly Journal of Studies on Alcohol 6, 500–514 | |
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| Quantum Change. New York: Guilford | |
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| The Common Sense of Drinking. Boston: Little, Brown, and Company | |
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| In search of how people change: Applications to addictive behaviors. American Psychologist 47(9), 1102–1114. | |
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| Alcohol: One Man's Meat. New York: The MacMillan Company | |
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| Tactical and Strategic Use of the Preferred Defense Structure of the Recovering Alcoholic. New York: National Council on Alcoholism, Inc | |
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| Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Bloomington, IL: Chestnut Health Systems | |
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| The history of recovered people as wounded healers: I. From Native America to the rise of the modern alcoholism movement. Alcoholism Treatment Quarterly 18(1), 1–23 | |
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