Michael R. Edelstein, PhD
Point Of View
REBT1 offers an alternative to the conventional view of addictions. No one is powerless over their drug/alcohol abuse, no matter what their past or current circumstances happen to be.
Rather, the immediate cause of addictions lies with the thoughts, beliefs, ideas in your head--what you tell yourself--immediately before you drink, overeat, smoke, or shoot up. Unrealistic thinking is the essential cause of addiction, and such thinking takes the form of "must's," "awful's," and "can't-stand-it's." By changing the thinking process, addictive behavior can be overcome. "I MUST get high! It's AWFUL to be deprived! I CAN'T STAND discomfort!" is the refrain of those addicted. Such "musty" notions lead to escape into drugs.
Individuals addict themselves to pleasurable experiences to escape discomfort, enhance good feelings, or both. Improving performance, fitting in with peers, and differentiating oneself from other groups (especially parents) are specific instances of these larger goals.
When you feel depressed, for example, you may drink excessively to drown these feelings. The next morning you may get depressed about your previous night's self-destructive behavior. This pattern illustrates how individuals with emotional and addiction problems often use addictions to escape their emotional difficulties. Emotional problems may also be created in response to addictions. This vicious circle has been labeled "dual diagnosis."
The addiction may be addressed separately from the emotional problem or in conjunction with it, depending on the circumstances of the client, the problem, or the therapeutic interaction.
Using addictions to escape disturbed emotions has also been labeled "self-medication." In other words, the individual drank in response to the initial depression as a way to "medicate" it away or escape from it. Prescription drugs may be used for this purpose, as well.
Integration With Team
"Epidemiological data from several countries show that substance abuse or dependence is common (25-50%) among persons disabled by severe mental disorders such as schizophrenia, bipolar disorder or chronic depression."2 Thus the importance of including addiction counseling as a part of the process.
The addiction counselor shares valuable insight with the other team members. For example, a report from the addiction counselor regarding resumed drug usage will help the psychotherapist understand any noted behavioral changes in the client. The reverse can also be true in that the addiction counselor can point out any behaviors typical of withdrawal.
Shared insight is reciprocal. Reports from other team members can facilitate the counselor's understanding of the particular triggers that led to addictive behaviors. Without communication between team members, the client loses important guidance.
Assessment Process
The first step in the assessment process involves understanding the client's perspective on the problem. This includes appreciating the circumstances and context of the problem and evaluating the client's long- and short-term goals. Some clients are clear that they drink or get high excessively, for example, and wish to quit for good. Others are unclear about whether they're overdoing it. Those who are convinced they're addicted, may ask whether abstinence or moderation makes sense for them. Some clients may have a mix of addiction and emotional disturbance and may not know how these are related. Others may have their addiction as a factor in the larger context of relationship difficulties.
The next step involves assessing which problem to address first. Although some clients show impatience and wish to address all their problems immediately, this is not possible. Do we address their addiction problem, emotional problem, or relationship problem initially? It's probably best to have the client decide. Simply and directly state the question: "which problem would you like to start with?" If the client is indifferent, then the therapist can determine which seems most pressing, and start with that. For example, if the client's partner has delivered an ultimatum, e.g., "If you get high again, I'm leaving," then under most circumstances it's prudent to focus immediately on helping the client to abstain.
The next step involves the education process: explaining how addiction is defined, where addictions come from, and how the fundamentals of the change process operate. REBT involves the backbone of our treatment. This approach is explained along with recommending further reading including Three Minute Therapy3 by this author and When AA Doesn't Work for You4 by Albert Ellis and Emmett Velten.
Goal Setting
Clients tend to have a variety of long-, medium-, and short-term goals in the process of overcoming an addiction. The most common long-term goal involves either quitting for good or moderation. Variations on this involve a middle-term goal of abstaining for a predetermined period followed by long-term moderation. Others begin with the long-term goal of moderation, and should this fail, abstinence as the default.
When a client is unsure about whether moderating or abstaining from drinking is reasonable, a look at history often provides the answer. Many compulsive drinkers have a history of attempting moderation and failing multiple times. This points to abstinence as probably the best solution.
"Do I reach my final goal by abstaining or tapering?," involves a common issue, especially for smokers. Since there is no perfect way of determining the answer in advance, I recommend taking a best guess at which is likely to be successful, then experimenting with it.
A final factor involved with overcoming addictions involves time frames for each step in the process. This is an individual choice based on history, including past failures and successes, and the consequences the addicted individual faces by continuing the self-defeating behavior. Some individuals quit overnight. Others take months or years of patience, persistence, learning from mistakes, relapses, and refusing to give up, before they ultimately succeed.
Treatment
REBT addiction counseling generally is conducted in-person or by phone. The average course of treatment involves 8-10 sessions, beginning with sessions weekly. As the client masters the REBT concepts and tools, and gets in control of the addictive behavior, sessions tend to get spread out over a few weeks, then monthly.
REBT follows an educational teacher-student, rather than a medical doctor-patient, model with sessions resembling a tutorial. After the initial assessment process described above, the therapist teaches the client concepts and strategies immediately applicable to the client's problem. Each session concludes with specific collaboratively-devised exercises for the client to practice daily between sessions. The following session begins by reviewing the homework, with modifications added based on the client's successes and failures with it during the week. If the client has immediate questions or concerns, addressing these would take precedence over the usual structure, with the homework reviewed after this.
The bulk of each session consists of reviewing tools and strategies the client may use in overcoming the addiction. These include: vividly reading a disadvantages list, refuting rationalizations, Three Minute Exercises, setting goals with rewards and penalties, and bibliotherapy. The client is encouraged to experiment with a variety of these to discover which ones prove most effective.
- Rational Emotive Bahavior Therapy - http://www.rebtnetwork.org/
- Psychiatry, Volume 3, Issue 10, Pages 60-63 R.DRAKE
- Edelstein, Dr. Michael R., Three Minute Therapy, 1997, Glenbridge Publishing, Colorado www.threeminutetherapy.com
- Ellis, Albert, and Velten, E., When AA Doesn't Work for You, 1992, Barricade Books, NY
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