…addicts can’t change their behaviors without help from God and wise counsel. None of us can find sufficient relief from pain without help. To expect something different from the… addict is to heap more shame on [them] and encourage Christians to respond to tough issues with simplistic solutions… We learn that we can make it if we just try harder and believe that those who haven’t made it didn’t try hard enough. But believing in ourselves and the fruit of our efforts works against the fact that we are sinful and can escape sinful behaviors only with God’s help.
Howard Hillman was a well-off executive consultant living with his second wife and her children in a tony suburb on the North Chicago shore. He was also an alcoholic who lived in denial of it due to his fairly competent functioning (which he grossly exaggerated).
His wholesome and successful veneer started to crack, however, after his second DUI in which he lost his license and had to hire his stepson to chauffer him around. He also had to engage in counseling in order to clear his record and get his license back, and was required to take a routine drug screen following his counseling intake. It was then that Howard’s even more secret addictions to oxycontin—which he had taken two years previous due to a severe back sprain—and to internet sexual pornography was discovered.
Now it all made sense to his wife. Howard had been cutting back on his drinking—she knew that as they had been fighting about it—but she didn’t understand why he slept in a stuporous state so much, had so many ‘minor’ accidents around the house, and no longer seemed to be interested in having sex with her. He was mixing alcohol with narcotics and internet sex! Worst of all, he had become a very accomplished liar.
It was then that it came out that Howard had been in a drunken car accident six months earlier, and had just paid cash to ‘persuade’ the other party to get their car fixed and keep quiet. His finances weren’t in good shape either, as he was buying his oxycontin on the black market, paying huge credit card bills for internet sex, and his consulting business was starting to slip.
For weeks Howard vacillated between anger at being found out, fear of losing his marriage, depression at facing reality, and shedding both real and crocodile tears as he promised over and over to “get sober” and turn his life around. The addictions group he was part of would hear none of it, as they confronted his lies, denial, and avoidance of the truth for weeks.
His counselor knew he was finally ready to get serious about change when he came to group one night and admitted to everyone there that he couldn’t change, that he really didn’t want to, but that he knew he had to if he was going to live.
Addictions are a very common scourge, the desperate expression of life in a sin-sick world. When addictions are piled on top of one another, or are mixed with mental illness, the suffering is multiplied and the cure is complex, difficult to accurately assess and easily achieve. Medicating the pain and symptoms of psychopathology—whether done under a doctor’s treatment or illicitly—is a primary pathway to addiction for many dual-disordered patients.
Dual disorders refer to someone who suffers both an addiction and a mental/emotional disorder of some kind. The prototypic sufferer is someone with depression or an anxiety disorder—some kind of felt dysphoria—who is also addicted to alcohol or other drugs that are usually used to medicate the pain of that dysphoric unpleasantness. And it is not unusual to encounter persons who live the process in reverse, as addictions will induce mental and physical suffering of various kinds, if carried on long and deep enough.
The 2003 National Survey on Drug Use and Health, formerly called the National Household Survey on Drug Abuse, is a project of the Substance Abuse and Mental Health Services Administration (SAMHSA), part of the U.S. Department of Health and Human Services. This survey interviews approximately 67,500 persons each year and is the primary source of information on the use and abuse of alcohol and illicit drugs by people in the United States, aged 12 years and older.
An estimated 119 million Americans aged 12 or older were current drinkers of alcohol in 2003 (50.1 percent). About 54 million (22.6 percent) participated in binge drinking at least once in the 30 days prior to the survey, and 16.1 million (6.8 percent) were heavy drinkers. These 2003 numbers are all similar to the corresponding estimates for 2002. The highest prevalence of binge and heavy drinking in 2003 was for young adults aged 18 to 25, with the peak rate of both measures occurring at age 21. The rate of binge drinking was 41.6 percent for young adults aged 18 to 25 and 47.8 percent at age 21. Heavy alcohol use was reported by 15.1 percent of persons aged 18 to 25 and by 18.7 percent of persons aged 21.
About 10.9 million persons aged 12 to 20 reported drinking alcohol in the month prior to the survey interview in 2003 (29.0 percent of this age group). Nearly 7.2 million (19.2 percent) were binge drinkers and 2.3 million (6.1 percent) were heavy drinkers. These 2003 rates were essentially the same as those obtained from the 2002 survey. An estimated 13.6 percent of persons aged 12 or older (32.3 million) drove under the influence of alcohol at least once in the 12 months prior to the interview in 2003 (a decrease from 14.2 percent in 2002).
Illicit Drug Use
In 2003, an estimated 19.5 million Americans, or 8.2 percent of the population aged 12 or older, were current illicit drug users, meaning use of an illicit drug during the month prior to the interview. There was no change in the overall rate of illicit drug use between 2002 and 2003. The rate of current illicit drug use among youths aged 12 to 17 did not change significantly between 2002 (11.6 percent) and 2003 (11.2 percent), and there were no changes for any specific drug. The rate of current marijuana use among youths was 8.2 percent in 2002 and 7.9 percent in 2003. There was a significant decline in lifetime marijuana use among youths, from 20.6 percent in 2002 to 19.6 percent in 2003. There also were decreases in rates of past year use of LSD (1.3 to 0.6 percent), Ecstasy (2.2 to 1.3 percent), and methamphetamine (0.9 to 0.7 percent).
Marijuana is the most commonly used illicit drug, with a rate of 6.2 percent (14.6 million) in 2003. An estimated 2.3 million persons (1.0 percent) were current cocaine users, 604,000 of whom used crack. Hallucinogens were used by 1.0 million persons, and there were an estimated 119,000 current heroin users. All of these 2003 estimates are similar to the estimates for 2002. The number of current users of Ecstasy (i.e., MDMA) decreased between 2002 and 2003, from 676,000 (0.3 percent) to 470,000 (0.2 percent). Although there were no significant changes in the past month use of other hallucinogens, there were significant declines in past year use of LSD (from 1 million to 558,000) and in past year overall hallucinogen use (from 4.7 million to 3.9 million) between 2002 and 2003, as well as in past year use of Ecstasy (from 3.2 million to 2.1 million).
An estimated 6.3 million persons were current users of psychotherapeutic drugs taken nonmedically. This represents 2.7 percent of the population aged 12 or older. An estimated 4.7 million used pain relievers, 1.8 million used tranquilizers, 1.2 million used stimulants, and 0.3 million used sedatives. The 2003 estimates are all similar to the corresponding estimates for 2002. There was a significant increase in lifetime nonmedical use of pain relievers between 2002 and 2003 among persons aged 12 or older, from 29.6 million to 31.2 million. Specific pain relievers with statistically significant increases in lifetime use were Vicodin®, Lortab®, or Lorcet® (from 13.1 million to 15.7 million); Percocet®, Percodan®, or Tylox® (from 9.7 million to 10.8 million); Hydrocodone (from 4.5 million to 5.7 million); OxyContin® (from 1.9 million to 2.8 million); methadone (from 0.9 million to 1.2 million); and Tramadol (from 52,000 to 186,000).
There were an estimated 2.6 million new marijuana users in 2003, or an average of 7,000 new users each day. About two thirds (69 percent) of these new marijuana users were under age 18, and about half (53 percent) were female. Decreases in initiation of both LSD (from 631,000 to 272,000) and Ecstasy (from 1.8 million to 1.1 million) were evident between 2001 and 2002, coinciding with an overall drop in hallucinogen incidence from 1.6 million to 1.1 million. Pain reliever incidence increased from 1990 (573,000 initiates) to 2000 (2.5 million). In 2001 and 2002, the number also was 2.5 million.
Rates of current illicit drug use varied significantly among the major racial/ethnic groups in 2003. Rates were highest among American Indians or Alaska Natives (12.1 percent), persons reporting two or more races (12.0 percent), and Native Hawaiians or Other Pacific Islanders (11.1 percent). Rates were 8.7 percent for blacks, 8.3 percent for whites, and 8.0 percent for Hispanics. Asians had the lowest rate at 3.8 percent. An estimated 18.2 percent of unemployed adults aged 18 or older were current illicit drug users in 2003 compared with 7.9 percent of those employed full time and 10.7 percent of those employed part time. However, most drug users were employed. Of the 16.7 million illicit drug users aged 18 or older in 2003, 12.4 million (74.3 percent) were employed either full or part time.
Substance Dependence or Abuse
An estimated 21.6 million Americans in 2003 were classified with substance dependence or abuse (9.1 percent of the total population aged 12 or older). Of these, 3.1 million were classified with dependence on or abuse of both alcohol and illicit drugs, 3.8 million were dependent on or abused illicit drugs but not alcohol, and 14.8 million were dependent on or abused alcohol but not illicit drugs. Between 2002 and 2003, a slight drop was noted in the number of persons with substance dependence or abuse (22.0 million in 2002 and 21.6 million in 2003).
In 2003, an estimated 17.0 percent of unemployed adults aged 18 or older were classified with dependence or abuse, while 10.2 percent of full-time employed adults and 10.3 percent of part-time employed adults were classified as such. However, most adults with substance dependence or abuse were employed either full or part time. Of the 19.4 million adults classified with dependence or abuse, 14.9 million (76.8 percent) were employed.
Substance Abuse Treatment
An estimated 3.3 million people aged 12 or older (1.4 percent of the population) received some kind of treatment for a problem related to the use of alcohol or illicit drugs in the 12 months prior to being interviewed in 2003. Of these, 1.2 million persons received treatment at a rehabilitation facility as an outpatient, 752,000 at a rehabilitation facility as an inpatient, 729,000 at a mental health center as an outpatient, 587,000 at a hospital as an inpatient, 377,000 at a private doctor’s office, 251,000 at an emergency room, and 206,000 at a prison or jail. Between 2002 and 2003, there were decreases in the number of persons treated for a substance use problem at a hospital as an inpatient, at a rehabilitation facility as an inpatient, at a mental health center as an outpatient, and at an emergency room.
In 2003, the estimated number of persons aged 12 or older needing treatment for an alcohol or illicit drug problem was 22.2 million (9.3 percent of the total population), about the same as in 2002 (22.8 million). The number needing but not receiving treatment also did not change between 2002 (20.5 million) and 2003 (20.3 million). However, a decline in the number receiving specialty treatment, from 2.3 million to 1.9 million, was statistically significant. This decline was driven by a decrease in treatment among adults aged 26 or older, from 1.7 million in 2002 to 1.2 million in 2003.
Of the 20.3 million people who needed but did not receive treatment in 2003, an estimated 1.0 million (5.1 percent) reported that they felt they needed treatment for their alcohol or drug problem. Of the 1.0 million persons who felt they needed treatment, 273,000 (26.3 percent) reported that they made an effort but were unable to get treatment and 764,000 (73.7 percent) reported making no effort to get treatment. Among the 1.0 million people who needed but did not receive treatment and felt they needed treatment, the most often reported reasons for not receiving treatment were not ready to stop using (41.2 percent), cost or insurance barriers (33.2 percent), reasons related to stigma (19.6 percent), and did not feel the need for treatment (at the time) or could handle the problem without treatment (17.2 percent).
Symptoms and Etiology of the Addict
The following list of 17 criteria is, in our opinion, a good set of common symptomatic behaviors and characteristics—a universal diagnostic set—that could be generalized to all substance or behavioral addictions and compulsions.
A pattern of out of control substance usage or behavior for a year or more.
Mood swings associated with usage or behavior.
An increasing pattern of usage or behavior over time. This increase may be a constant elevation or marked by periods of abstinence alternating with elevation.
The presence of major or milder forms of depression.
The feeling of shame or self-worthlessness.
The consistent need to be liked and find approval from others.
Impulse control problems, especially with food, sex, drugs, or money/spending/gambling.
Use of the substance of behavior to reward oneself or to reduce anxiety.
Obsessing about the substance or behavior, and spending great amounts of time around it.
Obtaining or doing the behavior becomes the central organizing principle of life.
Failed efforts to control the behavior.
Negative consequences due to the substance or behavior.
Alternating pattern of out-of-control behavior with over-controlling behavior.
A history of emotional, physical, sexual abuse, or spiritual abuse.
A family history of addiction, rigidity, divorce, or disengagement.
Marked feelings of loneliness or abandonment.
Arrested developmental issues.
The addict represents someone who has become trapped in a web of deceit and dark forces too powerful to overcome without significant help from God and others. Romans 7:21-25 reveals the truth about it:
“So I find this law at work: When I want to do good, evil is right there with me. For in my inner being I delight in God’s law; but I see another law at work in the members of my body, waging war against the law of my mind and making me a prisoner of the law of sin at work within my members. What a wretched man I am! Who will rescue me from this body of death? Thanks be to God-through Jesus Christ our Lord!” (NIV)
These words of the apostle Paul embody the spiritual journey of those struggling with addiction. The mind of an addict knows that he or she needs to stop using certain substances or doing certain behaviors, but seemingly can’t. They know that they must start doing positive behaviors, but won’t. It is the great conflict that Bill Wilson, the co-founder of Alcoholics Anonymous, captured in step one: “I admitted that I was powerless over alcohol and that my life had become unmanageable.”
Paul’s self description also reflects the shameful nature an addict’s self-perception when he says, “What a wretched man I am!” The feeling of being a bad and worthless person is common to all addicts. It is not only that addictive behavior produces shame; shame is a basic feeling that addicts have felt most of their lives. It is that addictive behavior perpetuates and inflames shame.
Addictive behaviors are problems per se, and they are also symptoms of deeper physical, emotional, and spiritual issues. Maintaining this dual awareness—as well as tolerating and appreciating the inherent tensions between these sometimes competing ideas—is important when working with dual-disordered addicts. Depending the issues of therapeutic focus, the course of treatment, and the progress (or lack thereof) toward goal attainment, the addiction is best viewed as either symptomatic of the underlying mental disorder or as the primary problem itself.
Addicts by their very nature feel helpless and unworthy. They are desperately asking as Paul did, “Who will rescue me?” Addicts cycle through feelings of the high of addiction and the despair of worthlessness. They may be stubbornly resisting giving up the high because they feel it is the only solution to the despair.
Counseling addicts is often frustrating as they frequently sabotage the most basic answers, tear down the most fragile progress. Competent Christian counseling must point them to the only lasting answer, a relationship with Jesus Christ. Treating persons with addiction and dual disorders assumes that competent Christian counselors will assess and understand the nature of what they are actually dealing with. Following are the classic factors that define addiction.
Understanding addiction must begin with what scientists are only beginning to understand about the human brain. Altering brain chemistry is at the heart of what creates and sustains addiction (see Amen, 1998; Milkman & Sunderwirth, 1987). Addicts seek to either raise or lower their mood using complex (and sometimes criminal) rituals of self-medicating behavior. If they are depressed, sad, or lonely they seek to raise their mood. If they are anxious, frightened, or stressed they seek to lower their mood. In doing so, addicts will eventually cause their brain to neuro-chemically “depend” on the substance or behavior.
We have long accepted that alcohol affects the chemistry of the brain. We can easily understand that other drugs such as marijuana, heroin, and cocaine (to name a few) change brain chemistry. Some scientists believe that nicotine might be the most addictive of all substances. Even caffeine can be considered as an addictive substance in its ability to raise mood as a facilitator or certain powerful brain chemicals, most notably dopamine, that elevate mood.
Addictive behavior and the brain. What has long been debated is whether or not certain behaviors can affect the chemistry of the brain. As scientists have increased their ability to scan and produce images of the brain (through MRI and PET studies, for example), research projects have begun to demonstrate that behaviors can also do this.
When a person looks at another person who he or she loves or has feelings of sexual attraction for, certain opiates (catecholamines) are produced more rapidly in the brain. These neuro-chemicals have a heroin-like quality in the pleasure centers of the brain. That is why some have suggested that we can become Addicted to Love (Arterburn, 19–). At Vanderbilt University, researchers are showing the dramatic effects on the brain of looking at pornography (Carnes, 1991). Little doubt remains that all sexual thought and activity produce these same neurochemical effects.
Any behavior that causes a sense of fear or excitement can raise levels of norepinephrine, more commonly referred to as adrenalin, in the brain. Norepinephrine can elevate levels of dopamine and serotonin and, as such, has a mood elevating quality. Gambling, working hard to meet deadlines, shopping, sports, even mountain climbing can become addictive for some.
The need for constant stimulation that some addicts experience means that their brains need ‘rapid firing’ to function properly. These persons are easily bored and distracted. They have problems thinking into the future and planning. As such, they may seem at times to be lazy or lacking discipline. In their academic careers they may have been labeled underachievers. Some addicts, then, may have neurological symptoms that reflect a level of attention deficit or hyperactivity disorder. Christian counselors will be careful to refer to competent psychiatric evaluation to evaluate these symptoms. Medications may be needed to balance an addict’s brain, at least for a time.
Multiple addictions. As our case example noted, many addicts suffer from more than one addiction. It is not uncommon for them to use a variety of substances and behaviors to alter their mood. Carnes (1991), in a research project with sex addicts, found, for example that half of all sex addicts suffer from chemical dependency. Carnes also found that the more serious the wounds of childhood, the more likely there would be multiple addictions.
This dynamic has led to many speculating about “cross addictions,” or the “co-morbidity” of addictions. Carnes is currently proposing a new and broad diagnosis, “Multiple Addiction Disorder” (MAD—an appropriate acronym). Christian counselors need to evaluate a broad pattern of addiction and triage which of the addictions is the most immediately destructive.
The Tolerance Effect
God has made us “fearfully and wonderfully” (Psalm 139: 14). One of the amazing qualities of the body is its ability to adapt. Whatever happens to the body it will always seek to return to the state of normal. Scientists and systems therapists call this homeostasis. A virus enters our body and the body works to expel it. If a person gets frightened and his heart rate increases, the body works to return it to the normal rate. What the body interprets as normal, however, can change if there is repeated challenge to the normal state of affairs. This is a powerful ability that God has created in all people, the power to adapt.
The first time an alcoholic drinks a beer, for example, he or she experiences the effects of that in the brain. Brain chemistry changes and feelings of intoxication begin. Eventually, the brain returns to normal and the person “sobers up.” If the pattern is repeated over and over again, however, the state of what normal is can change. More and more alcohol will be needed to have the same effect. This is what scientists refer to as “tolerance.”
The ‘tolerance effect’ can be experienced with any neuro-chemical change. Whether it is a substance that is ingested or a behavior that produces the change, the brain will eventually adapt. More and more of the substance or of the behavior will be needed. Over time a pattern develops and the activity increases. Addiction specialists usually describe this as “escalation” or as “deterioration” because the pattern gets worse.
Counselors must evaluate this pattern over time. Some addicts can quit the substance for a time but will eventually come back to it. They may alternate between periods of usage and periods of abstinence. This can even occur over a weekly cycle. Some alcoholics, for example, don’t drink during the week, but binge drink over the weekend. They may convince themselves that they have control because they can occasionally or regularly stop. The pattern over time, however, will always present with an increase in activity.
An 86-year-old minister’s wife presented with chemical dependency. She was addicted to alcohol and to prescription anxiety medicine. In her 20s she started having a glass of wine every few months. In her denomination, this was a major problem, so she kept doing it in secret. Over the next 60 years her pattern increased. She drank once a month, then once a week, then once a day. When I met her she was consuming a bottle of alcohol a day. Her drinking pattern was causing substance-induced anxiety and her doctor was medicating that. The pattern became a vicious cycle.
Neuro-chemical tolerance is the reason addicts crave a substance or some repetitive behavior. These cravings are what can seem to the addict to be out of control. They intend to stop but find themselves “drawn” back in. Smokers quit smoking many times but feel the urge to start again, and dieters start their dieting over many times, for example. Cycles like these fuel the feelings of being out of control.
Addicts often believe that sobriety is merely an act of the will, and therefore often come to feel they have no will power. As Christians, they assume that they should be able to stay ‘sober’ without much effort, or if they were just a little bit stronger spiritually they could stick with a decision to quit. Sometimes these attempts at self-control are extreme. In my first book about sexual addiction (Laaser, 1996), I described a case in which a man plucked out both of his eyes because Jesus said that “If you eye offends you, pluck it out,” and he was addicted to pornography.
Addicts pray fervently for help, even “deliverance” from their problems. They may try a variety of spiritual disciplines to stop. They pray, memorize scripture, meditate, join new churches, and attend Christian 12-step groups galore. Eventually they become discouraged. They have a critical choice to make. Either there is something wrong with them or with God. Anger at self produces shame. Anger at God produces periods of despair and spiritual alienation. It is a terrible dilemma but can also be the beginning of wisdom, for self-effort in all its myriad disguises must die.
Pride, fear, the need to be in control, and the unwillingness to completely surrender to God are also features of addiction and easily become inflamed at this stage (Kurtz, 1979). Some addicts are afraid of giving something up that they think has been helping them cope with life for years. Some believe that they can quit when they really want to. Others are afraid that if they confess their problems they will be judged and condemned. Fear of their feelings and fear of rejection lead addicts to deny their problem and hold on to them. In the midst of this chaos, some just give up trying. It is important for Christian counselors to assess for the willingness to get well.
Need for Nurture
Many addicts have feelings of loneliness and abandonment. They long for love, affirmation, nurture, and touch. In many cases the substance or behavior is a substitute for true love and fellowship. This may take many forms. Alcoholics may find a friend in the bottle or in the community of other drinkers. Alcohol allows many to be less inhibited and be friendlier and more out going. Food addicts may have certain comfort foods that they binge on. They remember that the act of eating may have been the only time they were being held as infants or gathered as a family. Sex addicts equate sex with love and assume that those who would be willing to be sexual with them, even prostitutes, offer them the only love, attention, and touch that they receive. Some who have been diagnosed as sex addicts may even be more in need of the romance and love experienced in their fantasies or in their affairs (Schaeffer, 2000).
Feelings of loneliness and abandonment lead to feelings of anger and resentment. Addicts wonder why their needs haven’t or aren’t being met. These feelings may be very old going back into childhood. They can be mad at their spouses or others for not meeting their needs. The sense of anger produces a sense of entitlement not unlike an angry child. Addicts think that they deserve to get their needs met and they deserve a reward. Loneliness drives anger and anger drives addicts past their own discipline and morals. This is a form of rebellion, as they really don’t care that they are acting out.
Assessment and Diagnosis
Most chemical addictions including alcoholism are defined by standard diagnostic codes (DSM-IV) as being Addiction or a lesser form of addiction, such as Substance Abuse. Some behavioral addictions such as a gambling addiction, and sex addiction are being debated in the medical and psychological communities on how to accurately define and include these disorders in the diagnostic system.
The ICD model—the International Classification of Diseases—defines six clear criteria for diagnosing a Substance Abuse disorder, whereby three or more of the following must have been experienced or exhibited at some time during the previous year:
Control problems: Difficulties in controlling substance-taking behavior in terms of its onset, termination, or levels of use
Compulsive use: A strong desire or sense of compulsion to take the substance.
Increasing/exclusive focus: Progressive neglect of alternative pleasures or interests because of psychoactive substance use, increased amount of time necessary to obtain or take the substance or to recover from its effects.
Continuing harm with denial: Persisting with substance use despite clear evidence of overtly harmful consequences, depressive mood states consequent to heavy use, or drug related impairment of reasoning, judgment, and cognitive functioning.
Tolerance effect: Evidence of tolerance, such that increased doses of the psychoactive substance are required in order to achieve effects originally produced by lower doses
Withdrawal symptoms: A physiological withdrawal state when substance use has ceased or been reduced, as evidence by: the characteristic withdrawal syndrome for the substance; or use of the same (or a closely related) substance with the intention of relieving or avoiding withdrawal symptoms
Intuition and discernment
My experience would also suggest that the spiritual intuition of the counselor is also important in diagnosis, as the self-perception of the addict are often notoriously inaccurate. Addicts who have come to a point of helplessness and perceived unmanageability are on the verge of owning their addiction, yet may also fight and deny that reality. The competent Christian counselor will be able to discern this struggle and will also know when the addicted person has not come to this point, even when they claim they have. Some addicts will still be in some state of denial and delusion about their problems, and will often lie about their readiness for change.
Accurate self-reporting may not be possible. The report of others, such as the spouse, or other family members will be important. An interesting form of assessment is to ask a potential addict how he or she theologically justifies acting out behavior. For example, how does an alcohol drinker justify drunken behavior, or how does a food addict justify the poor stewardship of being over weight, or how does a sex addict justify adultery, or how does a gambler justify chronic debt?
Multifaceted Addiction Treatment
The reasons for addiction are multi-faceted. The treatment of addiction, therefore, will also require a variety of approaches. Treatment must maintain a careful balance between confronting the addict’s denial and minimization and supporting them when they do the painful and difficult work of honest disclosure. At times, direct and intense confrontation is necessary because of the tendency for denial and minimization, but also remember that it is quite a threatening and shame-filled experience for a person to openly discuss the secrets and sins and despairs of their addictions. Following are the five classic areas that must be addressed:
Physical Stabilization and Self-care
Addicts may have caused physical damage to their bodies. Alcoholics will have possible neurological, gastro-intestinal, or liver complications. Food addicts may starve themselves to death or suffer the effects of chronic obesity. Sex addicts run the risk of sexually transmitted diseases or a variety of sexual dysfunctions. Any addict also runs the risk of stress resulting from chronic fear and anxiety, often due to the consequences of the addiction.
It is always wise for addicts to undergo complete medical evaluation. Alcoholics may need to even be hospitalized in order to stabilize the detoxification effect of stopping usage. Anorexics may also need to be stabilized in the hospital to prevent the effects of chronic malnutrition.
When stabilization has been achieved, it is always also wise for an addict to undergo a thorough neuro-psychiatric evaluation. Levels of depression must be determined. Assessment for the presence of a variety of forms of attention deficit disorder is also important. Some addicts will need pharmacological help for depression. Others will need different drugs that help manage the brains needs for constant stimulation. It is always wise to develop a relationship with a competent psychiatrist who can perform these kinds of evaluations.
Abstinence from the ‘drug’ of choice will, over time, deal with the level of neuro-chemical tolerance the addict has developed over the years. With help and sure accountability, alcoholics and drug users are able to achieve total abstinence from a substance. Food addicts may be able to abstain from certain kinds of food.
Those addicts who use a behavior or simply their thought life to achieve a neuro-chemical effect will have a harder time at abstaining, as secrecy is easier to maintain and accountability is so much more difficult. Some, like gamblers, can stop certain behaviors altogether. Sex addicts, however, can arouse themselves by fantasizing about sexual behavior can achieve the effect. Sex is perhaps the most notable example of this. The protocol with sex addicts is to have them abstain from all forms of sexual activity for a period of time, even if married, in order to achieve a detoxification effect from sinful sexual activity.
Finally, addicts will need to learn adequate self-care. As opposed to Paul’s teaching, they have been treating their body more like the city dump than the temple. Being tired or physically depleted makes any addict more vulnerable to acting out behavior.
Addicts have developed strong, highly programmed, even automatic behavior patterns in order to maintain their addiction. They will go to extraordinary lengths to deny, minimize, or rationalize this addictive behavior.
Focus on honesty and behavior change. This requires the therapist to maintain a strong initial focus on honesty and behavior change. When the addict seeks to divert discussion to family, emotional, or relationship concerns prematurely, the therapist must redirect attention to behavior. While effective treatment may address these issues, the clinician must help the addict stop using them to escape dealing with his or her addictive behavior.
One way of doing this is to link the tangential topics the client raises with the central issue of their addiction. For example, a counselor might refocus a client’s response toward the behavior in this way: “So how is the way you approach your anger toward your wife similar to the way you acted out your anger in your sex addiction?” “How is your tendency to denigrate yourself reflected in your addiction ritual?” The assumption here is that addiction has a life of its own and operates apart from other concerns. Unlike many other clinical issues, addiction is both symptom and disease.
Changing ritual behavior patterns. All addicts will need to change certain behavior patterns. Even those who engage in substance addictions need to evaluate behaviors that lead them into their use. These behaviors are usually referred to in the addiction community as “rituals.” The competent Christian counselor will help an addict assess the cycle of how he or she acts out. What behaviors always seem to lead to the addictive behaviors? Taking detailed histories of usage and behavioral patterns will be helpful.
When this information has been sorted out, addicts must establish boundaries against those behaviors. Alcoholics will need to avoid certain friends, areas of towns, or stressful situations that lead them to drink. Food addicts may even need to avoid going to the grocery store in the early days of recovery, or they may need to schedule meals at regular times and find help to eat at those times religiously. Sex addicts will need to avoid people and places that trigger them into their fantasies or “connecting” rituals. For example, those sex addicts who use the computer to connect will need to become accountable for every minute of access to it.
Can’t do it alone. I have never known an addict who can recover by him or herself. Yet, the average Christian feels that he or she should be strong enough to overcome this alone. Shame increases at the number of attempts to do so increases. The bible teaches that we should never undertake a long journey or complicated project alone. In Nehemiah 2, for example, the king allows Nehemiah to go home to rebuild the wall of the city of Jerusalem, but he also sends the army officers and cavalry. Later in chapter 4 of Nehemiah, the strategy is that half the men build and half the men stand guard.
Accountability in recovery. The key to recovering from any addiction is the need for accountability. All addicts need a number of people around them who help monitor behavior. These people will also provide support, encouragement, and affirmation. In the 12-step tradition of Alcoholics Anonymous, this is the power of the meeting and the people in it. Alcoholics have also learned they need a sponsor to help guide the process of accountability.
Addicts should not make the mistake of thinking that only one person could hold them accountable. They begin recovery believing that they are alone and abandoned. If they only have one person to be in accountability with, they may get triggered into their abandonment if that one person for whatever reason is not available. Addicts will need an accountability group, at least four or five people who really know them and whom they can call any time, day or night. Remembering that loneliness is a major factor in addiction, finding the fellowship of a group will be extremely important (The Twelve Steps, 1988).
There are innumerable 12 step types of groups today for many different addictions. These phone numbers can usually be found in the local yellow pages. More and more, Christians are trying to set up Christ centered support groups in local churches. In my field of sexual addiction, for example, several ministries are creating materials for such groups. Consult Web sites like faithfulandtrueministries.com for useful information. One Christian group, Overcomers Outreach (1994), has tried to create Christian materials for general addiction support groups.
The Nehemiah principle. Nehemiah, again in chapter 4, knew that the attack of the enemy could come at any time and at the weakest place. He prepared for this. Addicts will need to prepare in their times of strength and resolve to change for these times of weakness and attack. It is not enough to wait until the attack comes. Automatic and daily preparations should happen. For example, any addict should have daily phone calls from the accountability group and regular attendance at support groups even on those days or during those weeks when they don’t feel like they need to.
Following is a short list of accountability principles that should be followed by all addicts.
Never try to recover alone.
Fellowship is equal to freedom from addiction
Prepare in times of strength and resolve for times of attack and weakness.
Be in intimate accountability with at least four to five people.
Emotional and Cognitive Restructuring
Addicts come from families that might have wounded them emotionally, physically, sexually, and/or spiritually (Carnes, 1997). They have deep sadness, feelings of shame, and loneliness.
Protect against emotional triggers. It is vitally important for these emotional issues to be addressed. Any stimulus that potentially triggers an addict into these feelings can provoke the old answers, addictive activities that were used to medicate and change these feelings. These rationalizations and lies are referred to as “stinkin’ thinkin’” in the AA vernacular. Cognitive restructuring involves identification, confrontation, and correction of this erroneous thinking and this requires a psycho-educational approach. One principle to remember is that unhealed wounds often yield a relapse.
The competent Christian counselor will either be skilled in this kind of work or will know whom to refer to. The process of healing requires several factors:
Understanding the nature of the harm that caused the woundedness.
Providing support for the importance of dealing with it.
Accepting any anger that will be a part of the experience.
Allowing the person to grieve the losses associated with the woundedness.
Helping the person find meaning in the suffering of the experience.
Guiding the person in the process of forgiveness of those who caused the harm.
This is a process and should not be avoided. It is irresponsible to suggest that a person should just “forgive and forget.” It is also irresponsible to suggest that a person never let go of their anger so as not to get hurt again. Healing of life’s hurt can be a lifetime journey, but there are ways not to get stuck in sadness and anger.
Thought-stopping interventions. Every addict starts his or her acting out behavior by obsessing or fantasizing about the substance or behavior. This very thought life is an attempt to alter mood, to relieve pain. Christian counselors will hear the fantasies of addicts and know that they are windows into the mind and heart of the addicted person. Substances and behaviors are often ways that addicts seek to heal wounds from the past. It is mostly useless to tell an addict to stop thinking about a substance or behavior. Seek understanding for what the thought life, the fantasies, mean. If healing can be achieved for the wound that the fantasy seeks to correct, the fantasy will eventually disappear.
Covert sensitization. Another approach is to directly intervene in an addict’s fantasies. These fantasies are self-reinforcing because they are typically followed, in the case of a sex addict for example, by sexual arousal. In covert sensitization, the addict is instructed to articulate his or her preferred fantasy, and then to add to that fantasy an imagined aversive scene (such as the embarrassment of being caught and punished). Both exposing the secret fantasy and associating an aversive outcome reduces its attracting power. The goal is to reduce the reinforcement value of the fantasy by pairing it with an aversive consequence. Finally, the offender also adds a reward scene to the failed fantasy, emphasizing a positive outcome associated with successful control.
People who live with addicts know how painfully difficult it can be. Sometimes the spouses of addicts are referred to as “co-addicts” or “co-dependents” (Beattie, 1987). The assumption of terms like these is that they somehow ignore, tolerate and even enable addiction. Competent counseling will need to assess the emotional and spiritual health of people living with addicts. It is safe to continue to live with them if they don’t get help? Do co-addicts also suffer from their own wounds or addictions? It would not be uncommon for a spouse who lives with an alcoholic to also have drinking problems. My research has shown that about one third of spouses who live with sex addicts are also sex addicts.
Counselors should assess factors that brought spouses together. New theories are being developed which suggest that people find each other and seek to play out patterns of family of origin trauma with each other. Sex abuse survivors may, even unconsciously, find another sex abuse survivor to be in relationship with. The theory is that addicts may be trying to replay old patterns, going back into their families, in order to find a different result. Another form of this is that addicts will replay old family patterns, trying to be the one who controls the situation rather than the one who is victimized. The attempt to find healing from a relationship to a spouse for early life wounds is generally referred to as “trauma bonding.” (Carnes, 1997).
Counselors who deal with addicts and their spouses know that sometimes even the slightest of triggers can provoke rage, anxiety, or sadness. Deep healing work with both addict and spouse, together or individually, is vital to the restoration of marriage. Simple communication strategies or intimacy building exercises will not work in these situations. Work on the deep wounds with both partners is essential to helping these partners relate on the most basic of levels.
Suffer the little children. The children of addicts will inherently be wounded by addiction. Counselors will be progressive if they are able to address these issues and be of support for the entire family. It is not easy to engage family members, even spouses, if there is the addict to blame for all problems. Gentle forms of education and support can be helpful. Helping family members to be in support groups for others with similar problems can help them see their own responsibilities for the dysfunctions of entire family systems. Support groups of many kinds exist for those who live in relationship with addicts.
The healing of relationships is an essential part of treatment for addicts. Couples’ and family counseling is important. Addicts and those around them should be encouraged to be in networks of support. One of the best antidotes for addiction and co-addiction is fellowship with others. Addicts have a profound longing for nurture. Christian counselors must be able to help them find it in true and lasting relationships (see Carnes, Laaser, & Laaser, 2000).
The potential for developing intimacy and total self-honesty is crucial to addiction recovery. Addicts, in their shame, may feel that no one loves them and that if they talk about their most intimate feelings or reveal their worst acting out experiences, others will run from them. They will need to “practice” telling the truth to those, such as in a support group, who are less emotionally threatening than lifetime loved ones (e.g. spouses). They will then be able to take greater risks by being honest with loved ones.
Victim empathy. One useful strategies in treating addicts is to encourage them to develop empathy for loved ones hurt by their addiction. The addict is asked to try to understand, and even experience the pain they cause their victims. By maximizing empathy for others, it becomes more likely that the addict will treat others as persons, rather than as objects to be used for their own gratification. As addicts develop victim empathy and consider the consequences of their actions, they may present with suicidal ideation, shame, and guilt. Jesus incarnated victim empathy, and a counselors’ Christian background can aid in connecting the incongruence between client behavior and their spiritual worldview.
The road to recovery in relationship is long and labor intensive, but the possibility of profound intimacy with others is well worth the task.
Addicts are spiritually immature by nature. They often search for black-and-white answers to their problems. If addicts have developmental issues it is easy to see that they will also have childish and adolescent beliefs about God (see May, 1988; Miller, 1987). They may have become angry with God for not “delivering” them of their cravings, longings, and lust. There are several spiritual challenges for addicts when working with Christian counselors, pastors, and lay helpers:
Addicts must address their own need to control. Many of them may have committed to Christ intellectually, but not emotionally. They may be angry with God for not healing or delivering them. They have a hard time letting go of the high and the mood alteration of their addictive activities. Addicts have become accustomed to their ways. Being enslaved to addiction is what they know.
In the 13th and 14th chapters of the book of Numbers we find the story of how God is trying to prepare the people of Israel to go to the Promised Land. God has already done a mighty work in delivering them out of the land of Egypt. They are being led by one of greatest religious leaders of all time, Moses. Ten of twelve spies who have been sent to survey the new land give a negative report of how difficult it will be to go there because of “giants” in the land. In the opening of the 14th chapter, the people cry out for a new leader and declare that it would be better to go back to Egypt and die as slaves than to go to a place they don’t know.
This is how addicts often react. They don’t know a new place or a better way. They will want to hang on to the familiar. They are unable to trust God to see them through unknown and frightening future events. It is an issue of trust and total surrender. They will need to be guided to totally turn their lives over to God and face their own fears and need to control. In John 5, Jesus (our master psychologist) asks the paralyzed man at the pool of Bethesda, “Do you want to get well?” It seems like a silly question for a man who has been lying by this healing water for 38 years. The man, however, doesn’t answer affirmatively but instead gives excuses for why he hasn’t been able to get into the pool.
Christian counselors will also have to ask this hard question, “Do you want to get well and are you willing to take the risks, make the surrender, and do the hard work that will be necessary.” In Numbers 14, it is Joshua who says to the stubborn people, “We can do this with God’s help.”
Much of what has motivated addicts historically is fear and anxiety. They have sought to avoid consequences and trouble. They have been selfish in their pursuits. In recovery they will need to learn to be motivated for others. In Nehemiah 4, Nehemiah offers a great battle cry to the people. He tells them to fight for the brothers, sons and daughters, wives and their homes. This is better motivation for addicts. I have never known an addict who has recovered and found sobriety just for him or herself. The 12th step of Alcoholics Anonymous says that having had a spiritual awakening; addicts should carry the message to others. A motivation of service to others is an important part of maturing spiritually that is vital to getting well.
In Ephesians 5:1-3, Paul tells us that we should be “imitators of God, just as dearly loved children,” and that we should “lead a life of sacrifice, just as Christ love the Church.” Addicts must learn to lead a life of sacrifice, giving over their lusts and cravings. Addiction is selfish; recovery is self-less.
Addicts don’t know a better life. In most cases addicts don’t know true love and intimacy—they don’t know a true relationship with God. Addictions are embraced as the perverse substitutes—false love and false intimacy (Schaumburg, 1992). Christian counselors must be able to model to them what these things are like. An addict needs a true spiritual vision. One of the great challenges in working with addicts is in helping them exchange the short-term highs for long term truth. Intimacy with God and others is so much more satisfying than the high of any addiction.
When the Jewish people wanted to return to Egypt and live as slaves rather than go to the Promised Land, it was Joshua who reminded them to depend on God. Christian counselors will need to be like Joshua. Leaders like Joshua can also be found in those recovering people who have achieved a number of years of sobriety. These recovering people have assembled a more serene life and testimony of God’s ongoing work in their lives. Networking newly assessed and willing to recover addicts with these “old timers” is often one of the joys of Christian counseling.
Christian counselors are able to place more emphasis on spirituality in an appropriate clinical manner as the cornerstone of treatment. It is likely that addicts seeking Christian counselors have done so on purpose, and this can be a powerful beginning to recovery, as well as prognosis for continued alliance, rapport, and investment in treatment. Attitudes toward religion can also provide diagnostic clues. “By examining the patient’s religious views in the context of his or her personality dysfunctions, the clinician can differentiate between valid expression of spirituality and defensive religiosity” (Earle, Earle, & Osborn, 1995, p.12).
Putting It All Together
Nearly three decades of scientific research has yielded 13 fundamental principles that characterize effective drug abuse treatment. These principles are detailed in NIDA’s Principles of Drug Addiction Treatment: A Research-Based Guide, from the National Institute of Drug Abuse.
No single treatment is appropriate for all individuals. Matching treatment settings, interventions, and services to each patient’s problems and needs is critical.
Treatment needs to be readily available. Treatment applicants can be lost if treatment is not immediately available or readily accessible.
Effective treatment attends to multiple needs of the individual, not just his or her drug use. Treatment must address the individual’s drug use and associated medical, psychological, social, vocational, and legal problems.
At different times during treatment, a patient may develop a need for medical services, family therapy, vocational rehabilitation, and social and legal services.
Remaining in treatment for an adequate period of time is critical for treatment effectiveness. The time depends on an individual’s needs. For most patients, the threshold of significant improvement is reached at about 3 months in treatment. Additional treatment can produce further progress. Programs should include strategies to prevent patients from leaving treatment prematurely.
Individual and/or group counseling and other behavioral therapies are critical components of effective treatment for addiction. In therapy, patients address motivation, build skills to resist drug use, replace drug-using activities with constructive and rewarding nondrug-using activities, and improve problem-solving abilities. Behavioral therapy also facilitates interpersonal relationships.
Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. Methadone and levo-alpha-acetylmethodol (LAAM) help persons addicted to opiates stabilize their lives and reduce their drug use. Naltrexone is effective for some opiate addicts and some patients with co-occurring alcohol dependence. Nicotine patches or gum, or an oral medication, such as buproprion, can help persons addicted to nicotine.
Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way.
Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use. Medical detoxification manages the acute physical symptoms of withdrawal. For some individuals it is a precursor to effective drug addiction treatment.
Treatment does not need to be voluntary to be effective. Sanctions or enticements in the family, employment setting, or criminal justice system can significantly increase treatment entry, retention, and success.
Possible drug use during treatment must be monitored continuously. Monitoring a patient’s drug and alcohol use during treatment, such as through urinalysis, can help the patient withstand urges to use drugs. Such monitoring also can provide early evidence of drug use so that treatment can be adjusted.
Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases, and counseling to help patients modify or change behaviors that place them or others at risk of infection. Counseling can help patients avoid high-risk behavior and help people who are already infected manage their illness.
Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug use can occur during or after successful treatment episodes. Participation in self-help support programs during and following treatment often helps maintain abstinence.
Restoration and Relapse
In aftercare treatment planning, one must include a clear plan of restoration. This plan must include a great deal of accountability and ongoing oversight. Relapse and recidivism rates for addicts still remain relatively high after completion of treatment. One must be on guard to discern the role of spiritual transformation in the life of the addict. Addicts will say—and genuinely believe, along with many others supporting the addict—that they have committed or recommitted their lives to Christ, that God has forgiven their sin, and they have been healed from their addictive desires.
The implication is that if the therapist continues to insist on strong accountability or a need for continued treatment, they are doubting the power of God to change lives. This is very difficult bind for Christian counselors. On one hand we must seriously believe in the power of God to heal and change lives, while also being aware that healing is almost always a gradual process. Furthermore, the Christian counselor knows as well as anyone the subtle power of sin and the ways of the world to tempt the addict to use again. Even in the midst of the healing process, offenders can and do experience relapse—some relapse numerous times—but eventually establish control over the problem.
We must balance the need to affirm healing in the offender with appropriate concern for the reality of relapse and renewed addiction. The church, as a community of grace and healing, looks to the hope of the gospel for the power to change the behavior of addicted persons, to heal the wounds of the their victims, and to provide reconciliation with the body of Christ.
Working with addicts is usually both challenging and frustrating. A competent Christian counselor will often direct and guide an addict through a variety of resources and network of people. Sometimes the counselor will be like a team leader, shepherding counselors and others who are working with the addict, his or her spouse and children, and addressing other aspects of the problem.
Beware of those who don’t have willingness. One sign of an addict willing to recover is a felt sense of brokenness and humility. If you continue to run in to denial, selfishness, or stubbornness, don’t think that you have to be the one to make the final breakthrough. Establish your own boundaries of whom you are willing to work with. Even Jesus let some walk away. I often wonder how successful He must have felt as he hung on the cross and look at the lack of faith in those around him.
When you are thanked by those who have been broken, felt powerless, and who are working hard, you will see a growing life of peace and serenity, major life changes, and restored relationships. The personal, familial, and intergenerational cycle of addiction can be broken. This is what makes what we do so worthwhile.
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