Client Issues in Recovery

More often than not, substance abuse recovery involves an impossibly complex and painful process—one fraught with physical, emotional and spiritual perils, and one which invariably causes an addict or substance abuser to come to terms with a great many uncomfortable truths about self, severity of condition, and one’s prospects for actually maintaining sobriety (Lewis, Dana & Blevins, 2009).

Addiction and abusive consumption pathologies are rooted in the soil of imbalance, be it biochemical, behavioral, emotional, or psychosocial. Accordingly, the reasons that an individual might begin consumption of any substance are myriad, but are rapidly eclipsed by the reasons why he or she continues to consume (Beck, Wright, Newman & Liese, 1993; Czuchta & Johnson, 1998). The author believes that it is here--in the transitory area between a client’s simple use of a substance and their full-blown dependence upon it--where a therapist can find the greatest clues to how a person will approach and process recovery.

This concept begs several simple questions: What were the catalysts and are they still relevant today? What were the emotional, social and physical conditions associated with early consumption and continued use? What can the therapist learn about motivation in the client?  The author believes that asking these questions about the client’s state of being as addiction initially grew is the most effective way to understand the physical, psychological, behavioral, social, interpersonal, family and spiritual issues he or she will face in recovery. Knowing as much of the cause of client’s addiction can allow the therapist--in many instances--to learn about what recovery will look like (Beck et al., 1993; Czuchta & Johnson, 1998).

Perhaps the best place to start when framing these issues is to first understand how they are typically manifest in people. As previously mentioned, addiction finds its beginnings in imbalance and disproportionate responses and behaviors. Physically, this is primarily an issue of altered brain chemistry. In order to sustain a constant sensation of euphoria (and in late-stage addiction to keep from experiencing withdrawal) an addict or abuser will consume ever-increasing amounts of a given substance. In terms of emotional stability, an imbalance can be the result of childhood neglect or abuse, where an abuser or addict self-medicates as a means to quell a deep-seated pain. Behaviorally, an addict or abuser frequently seeks to level out imbalances that are the result of unhealthy interpersonal interactions or simple social learning, with addiction taking hold as the result of a lifestyle patterning and conscious choices.

The issues that one will face in recovery are--in the author’s opinion--directly related to the issues which led to the development of an addiction or abusive pathology, and in learning how the client sought to address those issues--to set right the imbalances that he or she experienced in life--a helping professional can begin to strategically anticipate the issues that will need to be addressed. Of critical importance for the therapist is to understand that wherever an issue (psychic, physical, spiritual, emotional, or otherwise) previously existed in a client’s life--but was addressed through consumption instead of targeted therapy or cognitive change--that issue will need to be visited once the “balancing” variable of the substance is removed from the equation (Czuchta & Johnson, 1998).

For people in recovery this translates rather simply into the client facing his or her major life issues without substances--many for the first time (Czuchta & Johnson, 1998; Lewis, Dana & Blevins, 2009). Typically, the physical, emotional and spiritual elements of a client’s life will be interconnected, each affecting the other in varied ways. Physical changes brought about by continued substance abuse can change every aspect of a client’s perceptions about family, religion and self, and more often than not this will generate both fear and reluctance during initial phases of recovery. When physical systems are not functioning properly the net impact on a person’s other life areas can be profound. Conversely, if a client is disenfranchised emotionally or spiritually, behaviors and physical symptoms can move to the fore as the client subconsciously works toward stability.

The author believes that because of the inter-connectivity between different areas of every human being’s life, all the major areas must be examined in in a way that honors the role each area plays. Viewing everything in flux--observing the push and pull of life’s major components--is the surest way to determine what issues a client must emphasize as they move through therapy.

To the author, addiction is less a tangible “thing” and more a place. In this place a client’s issues are the simple expression of the manner in which they respond to stress, pain, sadness, anger, anxiety, and myriad other issues. Instead of healthy management of these issues, addicts and abusers begin to respond to them with the typical behaviors of addiction: taking a drink, a hit, or a pill. To develop a healthy and sustainable approach to living--which happens in therapy and is continued in recovery--clients must learn to replace responsive habits with appropriate behaviors.

References

Beck, A.T., Wright, F.D., Newman, C.F., & Liese, B.S. (1993). Cognitive therapy of substance
abuse. New York: Guilford Press.
Lewis, J.A., Dana, R.Q., & Blevins, G.A. (2009). Substance abuse counseling (4th ed.). Belmont, CA: Brooks/Cole.
Czuchta, D.M., & Johnson, B.A. (1998). Reconstructing a sense of self in patients with chronic
mental illness. Perspectives in psychiatric care, 34(3), 31-36.

Diagnosis and Treatment Considerations for Bipolar Disorder

A Case History: Diagnosing and Treating Carol

In examining the case history of the fictitious client Carol—as she is described to the reader in Daley and Moss’ (2006) text—the counseling student quickly discovers a very troubled individual struggling with what outwardly appears to be bipolar disorder. One can effectively base such a determination on the fact that Carol meets virtually all of the conditions that are required to develop such a diagnosis: (1) She has been involved in intense personal relationships (with both men and women) where idealization and devaluation have each been central to actual outcomes; (2) She demonstrates a significant lack of impulse control (which is typically a means Carol employs to combat loneliness or feeling unwanted); (3) She is severely unstable in her overall affect and demonstrates a lack of control over her angry emotions (drunkenly confronting her parents at inopportune moments and demonstrating an inability or unwillingness to maintain employment); (4) She has demonstrated a recurring tendency to engage in suicidal actions or ideations (slitting her wrists and attempting to overdose); and (5) S has reported uncertainty about her own self-image and her own sexual identity (which is manifest as confusion about both preference of partners and her own proper gender).

With a client who has the same variety of issues as Carol and who behaves in a corresponding fashion, the author believes that it is critically important to rule out conditions other than bipolar disorder before actually making a final diagnosis. With Carol, several aspects of personality and behavior could easily be attributable to other conditions. For starters, much of her erratic behavior could be the exclusive result of her drug abuse (especially with cocaine and alcohol). What causes the author to abandon this premise (albeit reluctantly) is the sheer quantity of symptoms that align with the actual array of symptoms associated with bipolar disorder. Carol demonstrates virtually of them in concert, and although drugs and alcohol are central to the continuance of her mental health issues, they are not necessarily the primary cause of them.

If the author was serving as Carol’s therapist he would additionally endeavor to eliminate borderline personality disorder, schizophrenia, schizoaffective disorder, and delusional disorder as primary. Any one of these particular types of disorders could be indicated by each of Carol’s symptoms—either alone or in combination. The author would pay very close attention to these possible candidates because of the fact that they are so similar in terms of how they are visible in clients—each contains disturbances in cognition and emotion in a way that has both positive and negative undertones (Daley & Moss, 2006). Much like the “light and dark” associated with standard bipolar disorder, these conditions can have a very similar effect: Borderline personality disorder and delusional disorder can each include impulsive actions, suicidal behavior, irrational anger and paranoia, and schizophrenia and schizoaffective disorder can each include flattened emotions, ambivalence, a lack of goal-orientation in life, delusional thinking, and paranoia (DSM-IV-TR, 2000). What is critically important, in the author’s opinion, is to eliminate any of these as a stand-alone disorder prior to reaching a clinical conclusion that Carol suffers from bipolar disorder.

The author believes that upon reaching a firm understanding of what Carol was dealing with, the best treatment approach for Carol would be one that does not directly emphasize the concept of change in too direct a manner. Carol is clearly in a psychic space where her attachment to dramatic concepts regulates much of her ability to express herself and make cognitive determinations. As is true of many who suffer from bipolar disorder (DSM-IV-TR, 2000; Daley & Moss, 2006), Carol represents herself in constant crisis. One could even speculate that much of her problematic behavior stems directly from her commitment to this abstract ideal. The author’s approach would be one that gently affirmed small positive changes (as they occurred), and one that focused on providing support over immediate or forceful re-education. In moving across the continuum of care, the author believes that he could call on his strengths in creating trust and establishing an emphatic bond with Carol in order to develop the dual goal of sobriety and less manic interference with normal functionality.

This strategy would involve a cognitive-based campaign that targeted specific reasons or trigger behind problematic consumption (i.e. drinking in anger or frustration). In trying to establish alternative behaviors that could take the place of substance abuse at certain trigger-points, the author believes that enough solidarity and dissonance could be achieved to eliminate the need for halfway-house or inpatient care. However, this route would have to be weighed against two distinct aspects of Carol’s existence: (1) A history of certain enablers in life (i.e. her parents’ willingness to cover-up her behaviors; and (2) A demonstrated willingness or ability to maintain steady employment and control impulses in the future. The author would also work to reacquaint Carol with her natural intellectual capabilities with the intent of making this a central part of her goal-setting during treatment. Should Carol fail to respond to any part of this approach, however, the author would reconsider inpatient care on an as-needed basis.

 With clients like Carol, challenges do not end with successfully reaching a diagnosis. It would appear that instead this is actually a point of departure—that place where actual therapeutic progress can truly begin (Daley & Moss, 2006). The author believes there is a distinct need to adhere to the diagnostic criteria associated with a multitude of disorders, but not only to reach a successful diagnosis. The reality is that these criteria will continue to influence and guide how therapy unfolds throughout the therapeutic relationship. As always, what remains most important is a commitment to what the client’s demonstrated needs actually are.

References

 Daley, D.C. & Moss, H.B. (2002). Dual disorders: Counseling clients with chemical dependency and mental illness. Center City, MN: Hazelden Foundation. 

American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: APA.

Understanding the Prevalence of Substance Abuse Among HIV/AIDS Sufferers

Since the first moments that the human immunodeficiency virus (HIV) and its biological conclusion—the acquired immune deficiency syndrome (AIDS)—have been included in the American public’s consciousness about public health, most conversations surrounding the virus/syndrome have gravitated at some point toward a linkage with some type of detrimental or widely-unaccepted behavior (Batki, 1990; MacGowan et al., 1997). Whether this discourse is focused upon sexual behavior, illicit drug consumption or anything in between, the reason for this is as much a matter of perception as fact, and as a result the helping community is frequently presented with a tremendous number of challenges in garnering the required public support and resources required in order to provide care to those individuals whose lives are affected by both a substance abuse disorder and HIV/AIDS (Batki, 1990; MacGowan et al., 1997). Regardless of the credence behind the public’s perceptions about the linkage between HIV/AIDS and problematic consumption, the helping professional must keep in mind that the connection does indeed exist.

It would appear that this has been true as long as the HIV/AIDS pandemic has existed, although many of the trends associated with the relationship do not really speak to the origins of the disease itself. Instead, what most research points to is a mutually-reinforcing and highly destructive dichotomy where drug consumption is routinely a result of having the disease (Batki, 1990), and also conversely where the disease is both spread and intensified as a result of drug use (McCusker et al., 1994). The former is typically a matter of self-medication as the HIV/AIDS sufferer seeks to remove him or herself from the realities associated with having a terminal illness for which there is no known cure. The latter is generally a matter of drug users sharing HIV-infected needles, engaging in promiscuous behaviors (i.e. unprotected sex or sex with unfamiliar partners), or seeing their conditions worsen as the result of drug-toxicity further damaging an already frail immune system.

Despite the ease with which academic research can define the causal, almost cyclical nature of the connectivity between drug use and HIV/AIDS, the author feels that much of the associated prevalence should not necessarily be attributed to this alone. Certainly the cause-and-effect must be considered heavily, but not exclusively. This is especially true where prevention efforts are concerned. If the helping community fails to understand that such a cyclical dynamic cannot simply exist in a vacuum—which is to say that either HIV/AIDS or problematic drug consumption must come first—then targeted prevention will not be effective (Batki, 1990; Holmberg, 1996). The author believes, for instance, that if an individual frames the problem in terms of the original issue (either the disease or an addiction) then he or she can get the best idea of where to focus prevention efforts in any given region or community. If an individual sufferer developed HIV because of engaging in unprotected, risky sex (as opposed to sharing a needle) then a more effective focus of prevention might be community-based sexual education or condom distribution. If the primary contributor to an HIV/AIDS outbreak in a given region was due to intravenous drug users sharing needles, then prevention efforts would be best served by focusing on needle exchanges and drug cessation efforts.

Why is it important to point out such distinctions? The author feels that this is where the prevalence factor (of drug abuse amongst HIV/AIDS sufferers) finds it best expression. If an individual can break the problem into its separate parts and examine them independently, there are a tremendous number of lessons that can be learned about the trends behind each—trends which ultimately form a composite substance abuse disorder. Throughout this process, an emerging counselor can also begin to develop the best perspective about why simultaneous drug addiction and HIV/AIDS infection is a matter of comorbidity. The cognitive degenerations, typical mental health issues of an average sufferer, and socio-economic factors which can lead to either separate condition are all open to examination, and when this takes place the question of prevalence is answered (Holmberg, 1996; Langford et al., 2003).

Problematic drug consumption and addiction have—since time out of mind--been inextricably linked to the HIV/AIDS pandemic worldwide. For too long, many in both the helping community and in lay America believed that this was due to intravenous drug use and needle sharing, or just simple deviance on the part of the infected individual. However, framing the problem this way greatly undervalues not only the impact that drug abuse can have on the spread of HIV/AIDS through the unsafe behaviors it engenders, but also the parallel problem of how drug abuse and addiction can facilitate the advancement of HIV/AIDS infection because of how it further compromises the human immune system. Considering causation is critically important, and is perhaps the most important aspect of how the helping professional will perceive a larger interconnectedness between disease and addiction.

References

Batki, S.L. (1990). Drug abuse, psychiatric disorders, and AIDS: Dual and triple diagnosis. Western Journal of Medicine, 152(5), 547-552.
Holmberg, S.D. (1996). The estimated prevalence and incidence of HIV in 96 large U.S. metropolitan areas. American Journal of Public Health, 86(5), 642-654.
Langford, D., Adame, A., Grigorian, A., Grant, I., McCutchan, J.A., Ellis, R.J., Marcotte, T.D., and Masliah, E. (2003). Patterns of selective neuronal damage in methamphetamine-user AIDS patients. Journal of Acquired Immune Deficiency Syndromes, 34(5), 467-474.
MacGowan, R.J., Brackbill, R.M., Rugg, D.L., Swanson, N.M., Weinstein, B., Couchon, A., Scibak, J., Molde, S., McLaughlin, P., Barker, T., and Voigt, R. (1997). Sex, drugs and HIV counseling and testing: A prospective study of behavior-change among methadone-maintenance clients in New England. AIDS, 11(2), 229–235.
McCusker, J., Bigelow, C., Stoddard, A.M., and Zorn, M. Human immunodeficiency virus type 1 antibody status and change among drug abusers. (1994). Annals of Epidemiology, 4, 466-471.