Julie Bates offers a sobering thought to anyone who assumes that certain individuals choose a life of addiction. Bates, a doctoral candidate in counselor education at Penn State University, worked for three years at a methadone clinic in Massachusetts. One of her clients, a 23-year-old woman who exhibited track marks running from her shoulder down to her knuckles, had already been addicted to heroine and cocaine for a decade.

How had she gotten so far off track by the tender age of 13? Because her mother had injected her.

Bates, a member of the American Counseling Association, says that story stays with her wherever she goes, reminding her very clearly that clients with addictions need empathy and help, not judgment. While in treatment with Bates, the woman’s most difficult struggle involved rebuilding herself, redefining who she was after a decade of addiction and learning how to function as an adult without the addiction component.

In working with the woman for three years, Bates learned that addictions counseling is a long-term process. “Be patient,” she advises. “It’s not something that changes overnight or even over a couple months.” Although her client was able to stop using heroine after only about two months, it took closer to 10 months before there was any decrease in her cocaine use.

What helped the client finally make inroads in beating her addiction was writing letters to her mom, even though the letters were never mailed. In the beginning, the letters were positive, with the woman thanking her mom for her sacrifices and love. But as time went on, the letters became more “real,” Bates says, expressing such thoughts as, “Mom, you said you loved me, but you injected me when I was 13. What chance did I have?”

Through the process of writing the letters, the client realized she had been brought up to believe that when you love someone, you lessen their pain through drugs. Through counseling, she was able to tweak that worldview, learning that drugs do not equal love and that she was worthy of being loved on the basis of who she was, not what drugs she used or gave to others.

Counselors who don’t work in addiction clinics might not experience situations quite this extreme, but experts in the field warn that addictive behavior is often intertwined with many of the problems for which clients seek counseling. The realization that a client has addiction issues is daunting to many counselors who don’t specialize in that area. But Bates encourages those counselors not to turn away. “Don’t be afraid to talk to the client,” she says. “A big disservice would be ignoring [the addiction].”

Gerald Juhnke, professor and doctoral program director in the Department of Counseling at the University of Texas at San Antonio, says many clinical mental health counselors start their careers not wanting to work with anyone who has an addiction. In fact, Juhnke admits, when he set out in marriage and family counseling, he was one of those counselors who wanted to avoid addiction issues. But the reality is, when it comes to fairly common issues such as depression, anxiety or career and family problems, there is often an overlap with addictions, Juhnke says. Existing problems might compel a person to begin using drugs or alcohol or to engage in some other addictive behavior as a coping mechanism, or the problems the person presents with might be the result of a preexisting addiction. “Even though you don’t plan on seeing people with addictions, it will happen,” says Juhnke, a past president of the International Association of Addictions and Offender Counselors, a division of ACA, and former editor of theJournal of Addictions & Offender Counseling. “People rarely come in saying, ‘I have an addiction problem.’ They come in saying I lost my job, have problems in my family, etc.”

Sticking with an addicted client

Even when counselors don’t think they are skilled enough to work with addicted clients, Juhnke says automatically making a referral isn’t the best idea. Accredited master’s-level counseling programs include training in addictions work, so most counselors possess at least some knowledge in this area. Juhnke strongly recommends that counselors consult with a supervisor and then attempt to continue working with addicted clients. “The client might have a good relationship with you as the counselor,” he says. “If the counselor panics and says, ‘I can’t work with you anymore,’ then the client feels abandoned. They feel like, ‘I won’t tell anyone again that I have an addictions problem.’ If you’ve already got a good counseling relationship, don’t abandon the client. Get someone who can give you ideas and direction, and follow what they have to say,” advises Juhnke, who coauthored Counseling Addicted Families: An Integrated Assessment and Treatment Model with W. Bryce Hagedorn.

Kerrie Fineran, an assistant professor of counseling at the University of North Texas (UNT), offers similar advice to counselors who don’t specialize in addictions. She recommends that counselors seek supervision, educate themselves on the resources available in the community for addicted clients and refrain from automatically referring or including language in intake paperwork that indicates they won’t work with clients who are using. A referral may be necessary if a client needs help beyond what you’re able to provide, especially in cases in which outpatient therapy might not be enough, says Fineran, a member of ACA and IAAOC. “But the process of referral should be something that promotes hope and your belief in their ability to change and doesn’t destroy the trust they’ve built with you.”

If counselors are unsure about whether a client is exhibiting addictive behaviors, IAAOC President Juleen Buser says research often references the three C’s of addiction as a way to conceptualize some of the core characteristics. “Counselors can be on the lookout for these three C’s as they work with clients as a preliminary way to assess the presence of addiction: loss of control over addictive behaviors, despite the client’s aim to stop; compulsive use; and continued use regardless of negative consequences,” says Buser, assistant professor in the Department of Graduate Education, Leadership and Counseling at Rider University in Lawrenceville, N.J.

The addictions counseling field has made a significant transition over the past few decades, according to Juhnke. It used to be that most addictions counselors were former addicts in recovery, whereas now, Juhnke says, there is a movement of mental health professionals heading into the field with master’s-level degrees and a specialization in addictions work.

Juhnke notes the licensure situation regarding work with addicted clients can be complex. Requirements vary state to state, meaning that any licensed counselor might be permitted to practice addictions counseling in one state, while in another state, the counselor must also be licensed as a chemical dependency counselor to perform the same work. This can be frustrating and confusing, Juhnke acknowledges, especially for counselors with advanced degrees who are then informed they need yet another license to practice addictions counseling. On the positive side, he says, the effort to make the field more professional with licensed caregivers is laudable.

Although master’s counseling programs touch on addictions, Fineran says counselors who want to specialize in addictions work should seek additional training and continuing education opportunities such as conference presentations, workshops and specialty certification programs.

Addictions can come in the form of process or substance addictions, but regardless of form, addiction is still addiction, Juhnke says. “All addictions are very difficult. One isn’t more difficult than another. In general, substance disorders revolve around ingesting, inhaling, huffing, injecting or taking some type of substance. Process disorders generally revolve around ‘doing behaviors,’ such as gambling, shopping, eating, sex, pornography, running, weightlifting, etc. The No. 1 thing in treating addicted clients is respecting them and treating them as if they were your mother, father, sister or brother. Failure to treat persons with addictive disorders as a loved one first often results in misperceiving the client’s addictive behaviors as [being representative of] the person.”

Understanding the struggle

Students who enroll in Fineran’s drug and alcohol counseling class at UNT are going to feel deprived — and that’s just the way she wants it. Each semester, Fineran asks her students to commit to giving up a substance or a process for the duration of the course. The goal of the exercise is for the students to understand the process of addiction and develop empathy for the addicted clients with whom they’ll someday work.

“Many of them think that people with addictions should just stop, quit it and pull themselves up by the bootstraps,” says Fineran, who likewise commits to giving something up each semester. “It seems like a simple thing to stop something, but [with this exercise], they understand what the body goes through and what the mind goes through. They really struggle with it. They start to understand what individuals with these problems go through and gain an increased sense of empathy that they can tap into when working with individuals from this population.”

At the beginning of the course, about half of the students are excited to accept the challenge because they’ve been wanting to give something up but needed a nudge to follow through, Fineran says, while the other half are terrified and don’t see how the exercise will help them learn anything. By the end of the course, roughly 95 percent of the students say the exercise was an excellent tool that taught them about the process of addiction and about themselves.

Many of the students give up something that has a physical impact, such as cigarettes or caffeine, so it doesn’t take long for them to experience symptoms of withdrawal. Most of the students relapse at least once during the semester, so Fineran addresses that topic in class. Some of the students acknowledge that they simply no longer felt like abstaining, whereas others slip up without thinking, such as by ordering a Coke at a restaurant. Regardless of the reason, Fineran says, the students learn about the shame and guilt that accompany a relapse and, more important, learn about the process that led to their relapse. Fineran works with the students to create plans to recognize warning signs of a possible relapse and to head it off before it happens. The project is particularly worthwhile because these counselors-in-training may one day create similar plans with clients who have addictions, Fineran says.

The class also discusses how life presents continuing challenges in the recovery process. For instance, Fineran says, students who commit to giving up beer for the fall semester might not realize until later how this decision affects their football watching. Or perhaps they give up sweets only to realize what a challenge that will pose during the holidays. “They go home for Thanksgiving and find out what it’s like to live in a world where everyone else isn’t trying to give up what they’re trying to give up,” Fineran says.

In addition to giving up a substance or a process, Fineran asks her students to attend at least two recovery meetings in the community, followed by writing a personal reflection to share with their peers. The meetings are as impactful as the attempt to abstain from something, she says, because they show the students that real people — often those similar to themselves or even people they know — are struggling. In addition, students are often impressed and humbled by the sense of community and hope that they witness at the recovery meetings.

“People with addictions are often maligned,” says Juhnke, who requires students in his addictions classes to give up both a process and a substance for the semester in addition to attending multiple 12-step meetings. “We think they’re old drunks or old addicts and we shouldn’t pay attention to them. But if we think of them as moms, sisters, dads, etc., we see them as people, not as the behaviors.”

It can be easy to focus on the behaviors that often accompany an addiction — such as stealing, lying or cheating to secure another hit — without realizing that those behaviors take place as a result of a physical or psychological dependency, Juhnke says. “Take, for instance, an addict who steals his mom’s silverware or credit cards. We might say, ‘What a bad son.’ But those are the components of the addiction, not the person behind the addiction.” Putting his students in the shoes of an addicted person is an effective way of building empathy, Juhnke says.

Empathy is one of Carl Rogers’ core conditions of counseling, along with congruence and unconditional positive regard, but those conditions have a tendency of disappearing when the client has an addiction, Fineran says. “We often look at people and think, ‘Just quit! You lost your home, you lost your job, so just quit this.’ But empathy helps counselors see that clients with addictions aren’t really any different than other counseling clients.”

After their own struggles to give up a substance or a process, Fineran says most students realize that people with addictions are simply people with problems — just like everyone else. “It becomes less scary for them and less of a mystery about what addiction is about,” she says. “It’s really about people trying to make changes in their lives, which is the same as every other client who comes in who might not be addicted.”

“Without that empathy and understanding and care for our clients, I don’t understand how they could ever imagine that we believe in them,” Fineran says. “We need to believe in them. We need to believe that these people are worth the change.”

Motivation for change

Historically, treatment for clients with addictions has often been directive, confrontational and harsh, Fineran says, but the trend is moving toward a model that is more supportive and inclusive of Rogers’ core conditions. That’s good news, she says, because research shows people do better when they are encouraged and when someone helps them elicit their own motivation for change instead of simply “throwing the book at them.”

“One movement that has gained steam over the past two decades is a shift to treatment models such as motivational interviewing, which differ from earlier models that focused on more intensive confrontation of clients,” Buser says. “Motivational interviewing works from the premise that clients come to counseling at various levels of motivation. A counselor’s role is to meet the clients at their current level of motivation — not presuppose a client is ready for action when, in fact, [he or she] may only be contemplating the need for change.”

Buser says a counselor might first assess a client’s level of motivation and then work toward increasing that motivation. “Authors have discussed the use of scaling questions to assess readiness to change at the start of counseling. If a client is ambivalent about treatment, gentle questions and door openers can be used by the counselor to help the client explore this ambivalence. For example, a counselor might acknowledge the client’s tentativeness about change, while also pointing out the client’s dissatisfaction with at least certain elements of the addictive behavior.”

Empathy is a critical component of motivational interviewing, Buser says. “For example, clients who struggle with eating disorders, termed a process addiction, often hide their behaviors and experience a sense of embarrassment about … binge eating and purging behaviors. Empathy is critical in this sense, as clients will be more likely to open up and disclose their disordered eating practices if they feel accepted and understood by a counselor.”

Juhnke is also a proponent of motivational interviewing with addicted clients. Through the process of a counselor asking questions about which parts of a client’s life are going well and which parts are not, the client can reach a clearer understanding of what is going on in his or her life, he says. For instance, a client might present with marital problems, trouble holding a job or failing grades before the counselor figures out that an addiction is intertwined, Juhnke says. Although the client at first might deny that an addiction is part of the problem, as the counselor asks questions and the client continues to want a solution to the problem, he or she may begin thinking about the impact that addictive behaviors have on the situation. Motivational interviewing helps move clients from a precontemplative stage to a contemplative stage, Juhnke says, and often encourages them to “bite into the whole treatment process.”

If motivational interviewing doesn’t prove helpful, Juhnke next tries a solution-focused approach, which creates a target the client wishes to aim for. Instead of focusing on the problem and how bad it is, which can be overwhelming for the client, Juhnke says solution-focused techniques urge the client to think about what an improved life would look like and what changes need to take place to get there. “Clients can tell you what they need if you listen to them, and this allows them to have influence on the kind of treatment they need,” he says.

If a solution-focused technique isn’t the right fit for an addicted client, Juhnke recommends trying a cognitive behavioral approach in which the counselor helps the client gain insight into his or her addiction triggers and how to respond once those triggers hit. For example, with a client who comes home from work to an empty house, feels lonely and reaches for a beer, Juhnke might ask the individual for alternative ideas of how that void could be filled. Keep in mind, he cautions counselors, that the same solutions won’t work for every client.

Buser mentions additional therapies that are sometimes referred to as the “third wave” of addiction treatment, including narrative therapy. “Counseling strategies associated with this theory include externalizing the problem, which often involves naming the problem,” she says. “Counselors work to separate the addiction from the client, often by giving the addiction a name, such as ‘bulimia’ or ‘alcoholism.’ The idea is that, through this process of externalizing, clients will no longer internally connect with the addiction. Clients may come into counseling with the view that addiction is a part of them. In this narrative therapy technique, however, the addiction is cast as an external force, and the client takes on the role of actively working to fight against this addiction. Optimally, this reduces self-blame and inspires efforts to combat the addiction.”

A different kind of referral

Clients with addictions won’t always come through a counselor’s door by their own volition. Instead they arrive because they are mandated to counseling by the court system. Although that circumstance might appear to create an entirely different counseling situation, Rochelle Cade says much of the counseling process mirrors that used with other addicted clients. Another similarity is that empathy and unconditional positive regard remain crucial to the process, she says.

Cade, a visiting assistant professor at the University of Houston-Victoria who worked with court-mandated clients for five years, often allowed these clients to use the first or second session to “get things off their chest,” she says. Many clients are upset about why and how they were arrested, the court process, their punishment or their perceived treatment by a parole officer, among other things, Cade says. “In my experience, just listening with unconditional positive regard and empathy early in the counseling process is probably the single most effective intervention for establishing the counseling relationship with these clients. I have been told over and over again that no one else — not the arresting officer, attorney, judge, probation officer, family members, friends or bosses — just listens.”

Some people contend that clients who enter counseling of their own free will are more motivated or ready for the counseling process, says Cade, a member of ACA and IAAOC who serves on the editorial board for the Journal of Addictions & Offender Counseling. “Some would prefer that clients enter the counseling process with some insight into the problem or issue or at least have identified the issue for themselves. Court-mandated clients by title and referral do not usually meet these prerequisites for entering counseling.”

Although she uses the phrase “court-mandated,” Cade prefers to think of clients on a continuum of voluntarism rather than of dichotomies such as voluntary/involuntary or mandated/nonmandated. Many clients, not just those who are court-mandated, first come to counseling on the involuntary side of the continuum, she points out. For example, there is the client who goes to counseling because his wife threatens to divorce him or because his boss threatens to fire him if he doesn’t.

Although much of the counseling process is the same, Cade does acknowledge a few unique challenges in working with mandated clients. One is defining the identity of the counselor’s “client.” This most definitely includes the person in the room engaging in the counseling process but might also include the referral source, such as a judge, parole officer or case manager, or other elements of the community. Issues of confidentiality can also arise, she says. “Counselors, with a signed release of information from the client, complete progress reports and submit them to a probation officer, parole officer or case manager, report them to a drug or mental health court, or submit them to an attorney or judge,” Cade explains. “The counselor may abide by the ethical and/or legal parameters of confidentiality in providing these documents, but the recipient of the documents may not.”

Client autonomy can be another sticking point, Cade says, because when clients are referred through the legal system, typically, their “problem” has already been defined for them and the goals of their therapy have been predetermined. Many of Cade’s clients are ordered to participate in substance abuse counseling as a condition of probation for drug-related offenses. “The problem has been defined: marijuana use,” she says. “The goals have been established by the conditions of probation: Submit to urine analyses and have clean results, participate and complete counseling, and abstain from drug use.”

But if clients don’t agree that marijuana use is the problem or decide they’d simply like to decrease their use, that can be out of line with the court’s goals. “I have had several clients who smoked marijuana all day every day decide to cut their use to one joint at night before bed,” Cade says. “Is this reduction in marijuana use [considered] progress? According to the court, it is not. If the results of a urine analysis are positive for TCH, indicating the client is still using, [the court deems this a] lack of progress or failure to abstain from drug use.”

Termination often poses a final hurdle. Cade has had clients participate in counseling for several weeks or even months and then suddenly stop showing up, oftentimes because they’ve been sent to jail for probation violations, new offenses or other reasons. “When the client is incarcerated, the counselor does not have the opportunity to process the closure of counseling and ethically terminate the counseling process with the client,” she says.

Connecting the dots

Considering that people are complex, complicated beings, counselors say it’s not surprising that addictions often coexist with other issues. Certain personality disorders, including antisocial, borderline, narcissistic and dependent personality disorders, seem to have a “robust” connection with addictions, Juhnke says. Anxiety, depression and trauma also commonly accompany addictions, he says.

“Unresolved trauma can be common with many diagnostic subpopulations,” Juhnke says, “For example, I have often found my clients who fulfill Axis II borderline personality disorder have unresolved trauma resulting from sexual abuse or incest, or feelings — real or imagined — of abandonment by significant others. Drinking and drugging behaviors were common ways of attempting to cope with such unresolved or experienced trauma. Thus, asking clients about their history and paying close attention to potential traumatic unresolved issues is important.”

One client told Juhnke that drinking and using drugs were her way of dealing with feelings of abandonment after her ex-husband ran off with a younger woman. “She was able to clearly articulate why and how this unresolved trauma led to her addictive behaviors,” he says. “Removing her addictive behaviors without addressing the underlying trauma would have left her extremely vulnerable. Therefore, it is important to concurrently address any unresolved trauma and addictive behaviors.”

Grief and loss are also significantly interwoven with many addictions, Bates says, whether the losses occurred prior to the addiction beginning, were incurred as a direct result of the addiction or took place during the person’s recovery and set the client back. In circumstances in which clients were using when they experienced a loss, they may not have processed the loss properly and can come to counseling with built-up grief, Bates adds.

Common losses resulting from addictions are wide ranging, Bates says, and can include family, friendships, jobs/careers, freedom, health, finances and educational opportunities. Even in recovery, she says, addicted clients face the likelihood of loss, particularly as it relates to their friends and social identity because, in many cases, those things were tied to the person’s addiction. In losing the old support system, even if it was an unhealthy one, the person faces the daunting task of starting from scratch, Bates says.

“If you take the substance away, you have to reconstruct the identity,” Bates says. “When you have someone who hasn’t really had to form relationships without the presence of a substance, it can be hard to do. You have to relate to the new friends through personality, not through the substance. Sometimes it’s really difficult for people to do. They forget how to behave socially without the drug.”

Other losses that occur while the person is going through recovery, such as the death of a family member or a friend, can trigger a relapse, Bates cautions. Counselors should work with clients on the area of prevention, talking about how they can rebound from losses that might take place while they’re working through recovery.

Grief can also stem from giving up the addiction itself, Fineran says. “The addiction has been their best friend and their coping mechanism. When they give that up, there’s a process of grief they go through [in] reorienting to their lives without it.” Although counselors can focus on many positive aspects of recovery with clients, Fineran says it’s also imperative to recognize what clients might be giving up, such as the sense of comfort the addiction provided them when things weren’t going well and the people, places and things they fondly associate with the addiction.

Working through the grief

No matter what type of loss or when it occurs, Bates says the best thing counselors can do is to address it with addicted clients. Counselors don’t intentionally skip over grief work, she says, but sometimes more pressing concerns pop up in the context of addictions work, such as immediate health, safety and shelter concerns. But whenever possible, Bates suggests, counselors should remember to address losses the client has experienced along the way because those losses might be contributing to or sustaining the addiction. In many cases, she says, grief work enables the client to make better progress in recovery.

Bates says the focus of these interventions should be on recognizing both the positives and the negatives of the losses that addicted clients have experienced. One intervention Bates recommends is writing, whether it involves clients keeping a journal of their feelings and thoughts or writing letters. For instance, clients can write letters to the addictive substance, both ending the relationship and grieving the loss. Or they can write letters to their “using self,” such as “Dear using self, this is why I don’t want to be with you, this is what you took away from me, and this is what I’ll miss about you,” Bates says. A client in early recovery might write to his or her “recovering self,” explaining what he or she is looking forward to in the future.

“It’s really having them acknowledge what things they’re going to miss about the addiction, whether it’s numbing their feelings or feeling high when they need a pick-me-up,” Bates says. “It’s also remembering why we need to get rid of it and why it’s not useful.”

Whereas writing letters encourages clients to take the time to acknowledge both the positives and the negatives of their losses, journaling can help them create a log of their thought processes. Seeing their thoughts on paper aids addicted clients in identifying triggers and patterns they may have been unaware of previously, Bates says — for instance, how having a fight with a parent led to the client using afterward. The client’s journaling can also alert the counselor to grief and loss issues that had not come to light previously.

Another intervention Bates suggests is the creation of memory books, which can take either a positive or a negative focus. A client might make a positive memory book about a loved one who died, including what the client loved about that person, photos of the client and the loved one together and words or pictures cut out of magazines to describe the relationship. Creating the book can help the client process and acknowledge the loss, while memorializing the good things the person contributed to the client’s life.

On the other hand, Bates says, a negative memory book works well for addicted clients who are having a hard time ending their use. These clients might make a book about their addiction, including pictures of doctors or scars or any other bad memories associated with the addiction. “It’s a reminder of why I shouldn’t be using this, even if my body’s telling me I should,” Bates says.

Bates suggests additional techniques that can be helpful to clients dealing with addictions and grief, or addictions alone. Bibliotherapy is effective, she says, as is role-playing in groups, where clients can practice saying no to the addiction or work on new social interactions. Bates also recommends using music to help clients relax and having them draw or paint as a way of sketching out what their lives might look like with or without the addiction. Depending on the individual client’s coping skills, techniques such as guided imagery, meditation and progressive muscle relaxation can offer the client a tangible way of relaxing and regulating his or her body without a substance, Bates says.

Bates also points to Robert Helgoe’s book Hierarchy of Recovery: From Abstinence to Self-Actualization as a good resource for counselors working with addicted clients. Helgoe proposes two phases in recovery: the pull and the push. In the push phase, Bates says, addicts are pushed to remain sober to avoid the consequences of their addiction, such as jail time or liver failure. In the pull phase, the addict is pulled toward a new way of being and enjoying the rewards of recovery. Helgoe’s theory, Bates says, is that to move into the pull phase, a client must first fully grieve the addiction and all the losses associated with it.

Bates says counselors may find it worthwhile to talk with clients about the two phases and what will help them want to stay sober. “Consequences get you [the client] into treatment, but will they keep you here? We have to find something more valuable, and that’s [the client as a person],” she says. “If we can focus on the client as a thing of value, that’s worth working on.”

The spiritual side of addiction

Throughout history, spirituality and addictions have been linked, says Keith Morgen, assistant professor at Centenary College in Hackettstown, N.J., and a member of ACA. Using alcohol as an example, Morgen says that leading up to Prohibition, it was thought that alcoholics didn’t possess any morals, spirituality or godliness. “Addictions were considered as being immoral,” says Morgen, secretary-elect of IAAOC and chair of its Spirituality Committee. “[The thinking was], ‘Because they’re drinking or doing drugs, they’ve turned their backs on society or God.'”

But when Alcoholics Anonymous and the 12-step approach came into being in the 1930s, Morgen says spirituality became a source of strength and comfort for addicted individuals, a way to build themselves back up. “It’s a model for how [those with addictions] can spiritually exist in the world,” he says. The spirituality or higher power invoked in 12-step programs can be a traditional god or any other kind of spiritual, philosophical idea that guides one’s life, Morgen says. “When you do reach that last step, you’re said to have had a spiritual awakening. It’s at the end of the 12 steps, not the start. It helps you get to the point where you’re a spiritual, living member of the world around you.”

Reconnecting spiritually with family, friends, society and oneself is a key piece of the 12-step recovery, Morgen says. “The idea is that your addiction isolates you from the rest of the world. The 12 steps are a road map to get back to the world, the community, the people in your life and also yourself.”

Outside 12-step programs, spirituality can still be a crucial ingredient in the work that counselors do with addicted clients, Morgen says. Tackling spirituality is intimidating to many counselors, so Morgen recommends looking at it from the perspective of how clients see their place in the world — what they value and believe in, what gives them strength and what makes them feel full inside.

Counselors used to try to find out if clients had spirituality as a strength or coping mechanism and then wouldn’t delve any deeper, but they need to do more than simply “check the box” after asking the question, Morgen says. “If you conceptualize it as how [clients] have fulfillment, courage, strength, how they see the world — if all that stuff rolls into spirituality, you almost have to talk about that because that’s who the person is. To try to talk to [clients] about their issues, fears, addictions and trials without talking about values, beliefs, where it comes from, how it has meaning, how it shapes them, it’s almost impossible to do.”

Morgen’s advice to his fellow counselors is to understand that everyone has a different definition of spirituality, and each definition is right for that particular person. Even if clients don’t believe in a god or a higher power, just talking about their philosophical sense of what makes the world spin can be helpful to them, Morgen says.

What benefit can spirituality offer to addicted clients? For one thing, Morgen answers, it provides a point of reference. Many times, he says, in living with an addiction, what addicted individuals do, whom they hurt and what they lose become a blur to them. Spirituality provides these individuals a sense of foundation that they didn’t possess when they were in the throes of the addiction, Morgen says. “It gives you a way to look around and make sense of what’s gained, what’s lost, where you’ve come from, where you’re going and how you fit in to all of that. It gives you an ability to find some kind of meaning, direction and an anchor point.”

Recovery communities

Although popular among many people recovering from addiction, 12-step programs aren’t a perfect fit for everyone, says Gerald Juhnke, professor and doctoral program director in the Department of Counseling at the University of Texas at San Antonio. For clients who don’t connect with the spiritual emphasis of 12-step programs, Juhnke says a number of alternatives exist, including Rational Recovery and Secular Organizations for Sobriety.

Some clients might not be comfortable with the personal interactions that 12-step programs require throughout the various stages of recovery. “If that is the situation, the counselor needs to understand how to get the client the necessary environmental supports without 12-step programs,” says Juhnke, a past president of the International Association of Addictions and Offender Counselors, a division of ACA. “I must say, however, that it is exceptionally difficult to try to recover without changing one’s interactions with current ‘using’ friends. Twelve-step programing immediately provides a group of interpersonal supporters and a social environment where all are in recovery and most, if not all, are very supportive of the client’s personal recovery.”

Although the 12-step approach won’t work for every addicted client, Juhnke says one significant benefit of these programs is that they offer a good mix of people just beginning the recovery process with those who are further down the road. For those just starting out, he says, it can be vital to gain support from more experienced peers, while also being able to look to others for advice and wisdom when relapses occur.

— Lynne Shallcross

ACA addiction resources

The following books can be ordered directly through the ACA online bookstore at counseling.org/publications or by calling 800.422.2648 ext. 222.

• Developing Clinical Skills for Substance Abuse Counseling (order #72895) by Daniel Yalisove provides a framework for understanding substance abuse and teaches the basic concepts and skills necessary for effective counseling ($29.95 for ACA members; $44.95 for nonmembers).
• A Contemporary Approach to Substance Abuse and Addiction Counseling: A Counselor’s Guide to Application and Understanding (order #72888) by Ford Brooks and Bill McHenry offers a basic understanding of the nature of substance abuse and addiction, its progression and clinical interventions for college/university, school, and community/mental health agency settings ($35.95 for ACA members; $49.95 for nonmembers).
• Critical Incidents in Addictions Counseling (order #78058) edited by Virginia A. Kelly and Gerald A. Juhnke explores the opportunities and challenges of working with clients struggling with addiction ($19.95 for ACA members; $24.95 for nonmembers).

Lynne Shallcross is a senior writer for Counseling Today. Contact her at lshallcross@counseling.org.
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Spotlight on eating disorders

As an assistant professor in the Department of Graduate Education, Leadership & Counseling at Rider University, Juleen Buser’s work focuses on process addictions and, more specifically, eating disorders. Counseling Today asked Buser, president of the International Association of Addictions and Offender Counselors, a division of the American Counseling Association, for her thoughts on the circumstances surrounding eating disorders and possible effective treatments.

Tell us a little about clients with eating disorders. What are they struggling with?

Clients who struggle with eating disorder symptomatology may be struggling with either clinical or subclinical levels of eating disorders. Two major clinical eating disorders include anorexia nervosa and bulimia nervosa.

Anorexia nervosa involves self-starvation behavior, and diagnostic criteria include weight below normal standards and a flawed view of one’s body as overweight. Bulimia nervosa involves binge eating, which is characterized by consuming a large amount of calories in a relatively short time period, a sense of loss of control regarding this food consumption and subsequent compensatory behaviors, such as self-induced vomiting or laxative use. In the new DSM-5 revision, binge eating disorder is planned to be included as a clinical diagnosis. This disorder involves the binge eating behavior of bulimia nervosa but does not include the subsequent compensatory behaviors.

Prevalence rates for clinical eating disorders have been documented to range from approximately 1 percent to 3.5 percent and, overall, are more common among females than males. However, researchers have documented that many more women struggle with subclinical levels of eating disorders — that is, behaviors and attitudes that would not necessarily conform to the criteria for a clinical diagnosis but are nonetheless concerning. Clients struggling with subclinical forms of eatingdisorders may diet frequently, vomit after meals twice a month and engage in a range of other problematic behaviors. Evidence also suggests that subclinical eating disorders can progress to clinical eating disorders. Thus, early intervention efforts on the part of counselors are vital.

Clients who struggle with eating disorder symptoms may engage in their behaviors as a coping strategy. They may utilize, for example, binge eating and purging as a way to manage a range of stressors in their lives — including their distress about their bodies. Interestingly, some research has noted that binge eating and purging behaviors are, in some ways, effective coping strategies, as certain negative emotions have been found to decrease after a binge-purge episode. Yet, other negative emotions, such as shame, have been found to increase after binging and purging. This could be a point of intervention for counselors, who perhaps work from a motivational interviewing perspective and seek to help clients explore ambivalence about treatment.

What techniques are especially helpful?

The field has recommended a multidisciplinary treatment model when working withclients who struggle with eating disorder symptoms. For example, medical professionals are often necessary to assess and monitor the physical health of clients, and working with nutritionists can also be incredibly valuable forclients.

In terms of counseling techniques, therapies such as cognitive behavioral therapy have strong empirical support in the literature. Moreover, authors have also discussed the import of experiential strategies. For example, given that clients who struggle with eating disorders frequently have challenges verbalizing their emotions, art-based techniques can be instrumental in theprocess of accessing and expressing emotional experiences.

Prevention efforts are also crucial. Researchers have documented a range of risk factors for eating disorder development, including dissatisfaction with one’s body and thin-ideal internalization, which refers to an individual’s belief that the thin body shape, often lauded by the media, signifies beauty and is an ideal toward which to strive. Counselors can target these risk factors in prevention programs. For example, some prevention programs introduce the construct of thin-ideal internalization and help clients evaluate this thin ideal and become critical consumers of media messages.

— Lynne Shallcross