Disease Model of Addiction

     Working right now in drug and alcohol, I hear a lot that drug abuse and dependence is a disease. I have to say that I am very conflicted with that statement. Perhaps in the past I was more conflicted, but I still get negative twitches when someone calls their substance abuse condition a disease. I plan on talk about: 1) When the disease emerges after the behavior; 2) Why I didn't like the word disease; 3) Why behavior or disease might be better than the other; and 4) What I've heard from clients recently on the subject.

     I think that it is difficult to pinpoint a moment when the behavior of drinking/doing drugs turns into a disease. A behavior is something that involves thoughts, feelings, beliefs, etc. There is some level of choice involved and, as such, there is some level of control over the circumstance. A disease is different in that choice or motivation has nothing to do with it. Instead, a disease progresses seemingly without the consent of the victim and proceeds, sometimes, to rob that person of any further ability to stop it, through the destruction of relationships, communication, logical thought patterns, and positive expression of feelings. But the question still stands: When does the behavior turn into the disease?

     I guess that the logical answer, given the definitions, is that behavior develops into a disease when there is no more control over the action. When there is real chemical dependence, meaning that withdrawal symptoms are either bad enough to kill or distressful enough to inhibit normal or safe functioning, the person must continue or risk such consequences. Of course, there is no clean delineation between behavior and dependence here; in fact, it is possible that there is a middle stage where chemical dependence is starting to take root, but a strong enough verbal or psychic burst (whether coming from inside or external, though certainly an intrinsic shock would yield better results) might allow the person to kick the habit.

     There is some power in semantics, using certain words can either preclude or assist a client in gaining active recovery status. I think that words like "behavior" and "disease" themselves have power. Each one has positives and negatives. Behavior is positive in that it denotes a changeable variable, as most, if not all, behavior can at some point be altered for good or ill. Behavior can be a negative word here if we paralyze the client for not changing or for "mis-diagnosing" a disease as a behavior. Disease, likewise, has both positives and negatives assigned to it. Disease is positive if diagnosed correctly because it correctly describes the inability of change by choice. Disease is negative in that it can easily be seen as a crutch - a way to eschew responsibility off of the self and on to something out of their control.

     It is very much this last example that pushes me away from the word disease. At one point in the life of the addiction, there wasn't a disease. There was a repeated behavior. The person chose, for whatever reason, to continue the negative action until the consequences were so deeply embedded that a change in action was either impossible or inconsequential. I think that part of my issue with the word disease comes from the belief that these people deserve their predicament. This belief, of course, is shameful and without evidence. Logically, could we say that the first behavior was their fault? Logically . . . yes. But do they deserve to suffer? No, they do not. 

     I know that a lot of my current clients mention that they have a disease. For them, as long as they are no using the word as an excuse, its use is fine with me. I think that a happy medium, perhaps, between the two terms could be "condition." A condition has the dual meaning of being treatable and a little easier on the ears than the word disease. It's different from behavior in that it shows a certain amount of seriousness or semi-permanence than behavior can inherently imply. I don't think I'll be pushing the work condition in sessions, but I will think it to myself. 

     I think it important to mention that the recovery process from addiction is both behaviorally treated and medically assisted. To treat the "disease" through detox and medically-assisted rehabilitation methods and not to treat the behavioral issues that go along with it doesn't add up. It's kind of like balancing an equation. One side is the behavior and the other is the disease.

A Sense of Humor

     Is a sense of humor a good thing? It is an appropriate response in some situations, but an impolite one in others. That is the easy answer to the question. but the overarching, more black and white question still exists: When it comes down to it, the only possible answers being yes or no, is humor a force for good or ill? I almost write evil instead of ill, but didn't. These two words mean very different things. Evil categorizes a construct as abrasively negative; an abstract looking-to-do-one-harm phenomenon. Ill is more general than this, allowing for negative externalities, but not giving them an origin or starting identity. It can be passive or accidental.
     A person with humor can use it to draw attention to himself as well as away from himself. He or she uses it as a tool. One must ask himself if this implies that the intention of use of the tool is good or ill instead of the tool itself. After all, a sickle might be used to harvest grain or hurt an individual. But a gun or sword has really only one function.
     But is a person without humor better off than a person with? It's important here to say "better off" than "better." I think that humor is such a main part of current society that a person with no humor would experience very potent intrinsic and extrinsic anxiety to conform. This might lead to some kind of self-destruct.
     Humor is a great pressure-release, especially when heard. I think that most people, when discussing humor, mention only the comedian. But what about the audience? Humor heard has the ability to decrease anxiety and depression levels.

Difference Between Depth Psychotherapy and Life Skills Therapy

     There is a distinct difference between deep psychotherapy and life skills teaching. Perhaps differently put: There is a distinct difference between psychotherapy and counseling. I don't want to demean the counseling profession, but I think that the difference in training and job placement show this.

     A counselor is entrusted with certain clients. These clients tend to have undramatic symptoms. By no means am I saying that counselors don't treat  clients that are very "ill." What I am suggesting, which is no less salacious, is that the level of therapy is not as deep as many clinical practitioners. I am not adding psychiatry here because, I have heard and experienced in a number of situations, their lack of actual therapeutic technique is large. Some practitioners, like psychologists, have the training to go deeper with a client and really help them to understand themselves at a much deeper level. It seems to me that most counselor operate at the level of psycho-education - one that does not demand the time or training required of depth-based therapies.
     As far as environmental differences are concerned, the situations that these two groups find themselves in can be very different. Counselors find themselves in many different situations ranging from D&A to family, etc. I think that clinical psychologists/psychotherapists ten to see either the worst of the worst (i.e. those that society has cast out) or relatively normal clients in outpatient/private/voluntary settings.
    

Happiness For All, All the Time

     I think that a lot of people have a general misconception about the make-up of the populace. Many people want everybody to be happy and smiling. They think that this would lead to a better world. Would it? Is this what the individuals want? is this how the world should be? Is it a therapist's job to help? is this ethical?
     Simply put, I think that every person has the right, ethically, to be happy or unhappy. It's interesting, because even the word happy is subjective. Sometimes being angry is very positive. Better said: Someone can be happily angry! They need to expel/communicate/show that anger. Some people revel in being depressed, as if this is their main mode of expression. And that's OK! As long as they aren't impinging on someone else's happiness, then they can behave as they see fit.
     The world would be much  more boring if everyone were stereo-typically happy. Sure, there wouldn't be war, but the lack of diversity in emotion would lead to a lack of diversity in thought and behavior. It almost follows that this homogeneity of affect could depress people. So, to answer the first posed question - no, I don't think that the world would be a better place.
     To some degree I think I've already answered the second question. It's true that one would not know what happiness was without sadness, anger, or melancholy. So, in effect, happiness would cease to exist. Back to the question: It's hard for me to believe that a lack of diversity of emotion would be valued. This would mean that everything in everyone's life goes well (which is impossible) or that they are a master of their own personal emotional status.
     I think that it is a therapist's job to help people learn to control themselves, to keep their "stuff" within arm's reach, not letting get it all get out and affect others. This could translate into greater societal change many years down the road. I think that it's also important to mention that most people can do this to some degree. They have the ability to self-regulate. True, things can get away from them and touch their families (who can also be within arm's reach), but hopefully those relationships are compassionate and forgiving enough to deal with it.
     I do not think that it is ethical to try to change clients. It's just not our job. Our job is to help the client understand themselves enough to allow the change to occur, if wanted. This type of treatment is deep therapy at its purest. No single technique or type of psychotherapy can achieve this. Fortunately or unfortunately, this type of change normally takes time and a good set of tools. Clients must choose to change themselves. We cannot force it. There is no mold that we should be pushing them into. I think that that is a main problem in current strategies in psychotherapy.
     I made a point in a previous paragraph that requires a sentence or two of elaboration. Everyone being happy would lead, most likely, to depression. If this is in fact true, then a world that is only happy is almost, by definition, unsustainable. It's impossible for people to be happy forever or to be happy constantly.

Is Showing Emotion Appropriate?

     If we were to split up the practitioners of psychotherapy into to distinct groups, I think that one criterion that splits them might have to do with the relationship the therapist has with emotion. Better said: Will the facilitator allow himself or herself to feel with/due to the client? Feeling takes real energy from the practitioner that can manifest later or can crop up outside the relationship. It could also be a subjective marker for the client. Does feeling help the therapy process? Perhaps feeling leads to ethical dilemmas. Many of those sound, negative but assuredly there is much that is positive here.
     As far as different theories are concerned, I think that we can all agree that fundamentalist clinicians, if such a thing were to exist, would come down on one side of this argument. More humanistic practitioners would describe the importance of being in the  moment with the client, experiencing what they are experiencing to some degree. More cognitive therapists, by nature, would eschew such tactics and really heavily on the thought process of the client. Both the nature of the therapy and role of the clinician as expert would not really allow the therapist the space to identify the clients/their own emotional circumstances.
     Were the therapist to allow himself or herself to feel, would there be any negative side effects in the session? Sure, emotions can be distracting. The clinician must not only track and pursue the emotions of the client, but must also keep a tight hold on his or her own feelings. These could cloud the counselor's judgement, disallowing good therapy to occur. It is very possible that, based on a clinician's own past, an intervention could fail. Feeling also takes up energy that the therapist could use thinking, filling out paperwork, or relaxing.
     The client must e taken into account as well. Does he or she respect the emotional spectrum? Is there a previous diagnosis that precludes accessing emotional data? Just as the style of therapy should match the therapist, of course that same style should match the client. There are some who either militantly do not wish to access their emotions, or are so cognitive that emotions play little part in their lives. With these clients, showing what the therapist feels would be uncomfortable and, for them, almost bordering on inappropriate.
     Feeling emotions is one thing, but showing them is altogether different. While the argument for or against showing emotions is not over, I'd like to cover this. Some clients would like the therapist to show some kind of emotion - this could vary from a slight pinching in the eyes  in empathetic pain, to openly weeping.  Personally, I would say that the former is better than the latter. There are some clients that might take advantage of the therapist of the latter emotional persuasion. Covering up emotions can also take up important time and energy that could be used for other things.
     Opinion time: I am an advocate of the therapist feeling in session. There are some definite negative possibilities to the equation there, though. A therapist can choose to act on the feelings, engaging in either predatory, maleficent, or sexual acts with the client. This probably isn't the best option. Some other negatives are listed above. Emotional therapists can also use their feelings as tools. They can deduce, though their own state, what the clients if feeling. They can also attempt to use this superpower to try to predict behavior.

REBT as Technique, not Therapy or The Disadvantage of Logic in Therapy

     I think a lot about the elegance of certain psychotherapeutic theories. One that comes up quite a bit is Rational Emotive Behavior Therapy (REBT). Certainly it is a very elegant theory. The way Ellis connects thoughts, beliefs, and feelings through the use of logic is a great technique. It is the logic part that we must discuss.
     Ellis was a very logical guy. He used that innate logic, coupled with a review of some philosophy, to create REBT. This is all well and good, but we must ask ourselves whether a theory based strictly upon logic is good. Most of our clients are "stuck." Their "logic processes" are malfunctioning and they need someone to help these processors get up and running again. It seems to me that logicking a client to death might be somewhat counterproductive.
     As we know, Ellis simplifies REBT through the use of the alphabet. "A" means activating event or antecedent, representing an event that has occurred that "sets off" the following behaviors. "B" means irrational/illogical belief - we'll come back to this. "C" is an emotional consequence that is normally negative (and thus the reason someone is coming to therapy). Ellis said that many people that outside situations or actions (A) affect them, created their distress (C). What they failed to grasp is the ever elusive B. The person's illogical belief, their interpretation, of A led to their disturbance. He would dispute (D) their thought pattern until they saw the light.
     Disputing, in my view, can only go so far. This is especially true when the disputer talks from a standpoint of expertise. This tends to sound high and might to many clients, which can undermine any helpful tendencies of therapy. I think that it might be better to work with the client and that disputing a claim rather than discussing it is probably an incorrect approach.
     I know I wrote that a theory based strictly upon logic probably isn't all that great. I would like to explain this. A lot of other theory is very metaphor-based, meaning that, to some degree, it is constructed with a good amount of wiggle room and space for project and interpretation. It leaves room for interpretation. REBT does not. It espouses an idea of total correctness. Is it correct? In its limited scope, yes. But there is much more to psychotherapy, "stuckness," and a client than the relationship between beliefs, feelings, and thoughts.
     I think that REBT is better categorized not as a psychotherapeutic discipline, but rather as an effective group of techniques whose goal is to use psychoeducational techniques to help clients with their understanding of basic relationships between beliefs, feelings, and thoughts.

Interplay between Thoughts, Emotions, and Beliefs

     I think that it's about time to struggle through the trinity of experience explainers.  This trinity, is, of course, thoughts, feelings, and beliefs.  To some degree, I think that behaviors should be thought of as part of that system, but behaviors don't explain, they are the explanations.  Better said: behaviors are the end result of feelings, beliefs, or thoughts - they are the effect to thoughts', feelings', and beliefs' cause.  I think that there is very little that can be described as "pure behavior."  One could cite reaction as pure behavior, but something started or informed such action - some previous thought, deep feeling, or belief.  The experience explainers are precursors to all behavior as action cannot occur without thought or due to some deeply-rooted feeling or belief.
     So what is the difference between these three states?  Where do they come from?  How are they linked?  How/why are they so easily misunderstood or mislabeled?  First, I'll try to define each one.  1) Thoughts:  Thoughts are reason in electrical form.  A true thought is complete, meaning that its very reason for existing is known.  It exists in order to explain, or help explain, something.  A thought is refined.  Thoughts are created when problems are introduced  and a reasoning chain is used to overcome it.  Logic can be used to develop a thought, but there are indeed many that are formed without its consent.
     2) Feelings:  Feeling are  much more primal than thoughts.  The previously-mentioned reactions have more to do with feelings than they do with thoughts.  Just as thoughts are refined through some kind of process, feelings most often aren't, or, perhaps, can't be.  To think through a feeling strips it of its raw, primal nature, and transforms it, by definition, into a thought.  In this way, we can say that feelings are precursors to thoughts.  Whereas thoughts are a very cerebral ornament, feelings are less so.  I very much hesitate to say that they are reptilian, as I do not know for sure if reptiles or similarly "un-evolved" animals have the capacity for higher-order feelings.  Feelings can be based on the old adage of "mad, sad, bad, glad."  Most feelings can be added to one of these headings.  Feelings are created when an experience upsets or supports previously-held beliefs.
     3) Beliefs:  I think that beliefs are some of the most interesting constructs we know about.  Beliefs are thoughts without evidence.  One believes something only when a thought is impossible because reasoning cannot adequately occur.  One must take a belief on faith.  I don't really mean the same faith as religion, but a similar one that requires adherence without proof.  Beliefs are inherently illogical.  Logicality is the domain of thought.  Violating a belief normally causes a negative feeling.
     REBT would tell us that when we experience something less than savory, a belief is called into question, leaving us with a bitter feeling.  It is only through complete and logical thought that the healing process can occur.  I think that this makes sense, but that the CBTers are speaking to their boathouse on this one.  OF COURSE thought would be the end result for a cognitive therapist.  Emotion-focused theorists think that the examination of feelings (rather than the interplay under REBT) are the true path to understanding the self.  Beliefs, it seems to me, are the jurisdiction of none (at least in the sense of this post).
     I think that beliefs have no part in therapy or in everyday life.  Beliefs are abstract, not thought through, and due to a lack of evidence, can really get a client into trouble.  To some degree, I think that it is a therapist's job to help a client explore their beliefs and discard those that are so illogical that thought is not permitted and feelings run rampant.