Running head: COMPARING AND CONTRASTING VIEWS OF ADDICTION
Comparing and Contrasting Biblical and
Professional Views of Addiction
This paper compares and contrasts the biblical view of addiction counseling with the historical and current professional standpoint. This is achieved by carefully inspecting from a biblical perspective the meanings and usages of terms such as counsel, advice, wine, strong drink, abstinence, and others. This paper will also present the definition, etiology, assessment, diagnosis, consequences, and intervention strategies related to addiction. Finally, the last section will provide personal insights and applications.
Comparing and Contrasting Biblical and
Professional Views of Addiction
As the fabled emperor proudly paraded around in his new clothes, the whole hamlet knew there was a problem except the naked, self-deceived ruler. Similarly, the common threads that bind most substance abusers are denial and destructive behavior. Kanel (2007) summarized substance dependence as “a maladaptive pattern of substance abuse leading to clinically significant impairment or distress” (p. 169). Clients who present with alcohol dependence or abuse have a vice-grip hold on defenses which include denial, displacement, fantasy, projection, rationalization, minimizing, and repression (Kanel, 2007, pp. 174-175). For example, Kanel (2007) asserts, “Denial is strong in these types of clients because most of them who come in for counseling are still capable of functioning on the job; therefore, they do not see themselves as addicts” (p. 175). However, denial does not cover the problem nor the devastating consequences.
Nationally, researchers have estimated a staggering 40% of all traffic crash fatalities are alcohol related (NIAA, 2010). Research has also demonstrated that most high school students “started their drug involvement with beer or wine. The second stage involved hard liquor, cigarettes, or both.” In the third stage, teens moved on to illicit drug use (Ksir, Hart, & Oakley, 2009, p. 17). In addition, “in 2008, 51.6% of Americans age 12 and older had used alcohol at least once in the 30 days prior to being surveyed” (NIDA, 2010). The estimated cost of alcohol abuse and alcoholism to the United States is in the billions—a sobering thought, especially in our current economic distress (NIAA, 2010).
The purpose of this paper is to compare and contrast the biblical view of addiction counseling with the historical and current professional standpoint. This goal will be achieved by carefully inspecting from a biblical perspective the meanings and usages of terms such as counsel, advice, wisdom, plan, purpose, instruction, and help as well as words related to addiction which include wine, strong drink, desire, self-control, and abstinence.
Secondly, this paper will compare and contrast the professional view of counseling versus biblical counseling as related to addiction. This section will present the definition, etiology, assessment, diagnosis, consequences, and intervention strategies related to addiction. Finally, the last section will provide personal insights and applications. Biblical Words Related to Counseling
To grasp the message of a song, it is necessary to dissect the lyrics. Likewise, to comprehend the philosophy and purpose of counseling, the meaning of the words related to it must be defined and understood. According to a biblical worldview, the first word to be defined is “counsel.” Counsel
The word “counsel” in the Bible is derived from different Hebrew, Aramaic, and Greek words. The word definitions were derived from the Blue Letter Bible (2010) website which provides the meanings of the words from Strong’s Exhaustive Concordance of the Bible. A sample of Old Testament (OT) usages from the New King James Version (NKJV) and the King James Version (KJV) are as follows:
a. Ya‘ats (verb)—means “to advise, to consult, devise, or plan.” David joyfully proclaimed, “I will bless the LORD who has given me counsel (ya‘ats)” (Psalm 16:7 NKJV). David identified the Lord as being the source of good counsel.
b. Dabar (noun)—refers to “a saying or speech.” The counsel (dabar) of Balaam led the Israelites away from the Lord which resulted in severe judgment (Numbers 31:16). From this Hebrew usage, counseling can be understood as much more than simply listening to clients. Listening plays a large part in establishing a working alliance, but counseling also involves the counselor supplying verbal input, albeit, better counsel than Balaam’s.
c. ‘Etsah (noun)—means “advice or purpose.” This word is akin to the Greek word boule. Clinton and Ohlschlager (2002) discovered that, “The word occurs more than a hundred times in the Septuagint, where it is used seventy-four times to translate the Hebrew word etzah” (p. 59). Usage of this word in both Psalm 33:10-11 and Psalm 1 demonstrate that there are basically two types of counsel: either ungodly or godly. “The LORD bringeth the counsel (‘etsah) of the heathen to nought: He maketh the devices of the people of none effect. The counsel (‘etsah) of the LORD standeth for ever, the thoughts of His heart to all generations” (Psalm 33:10-11 KJV). This word is also used in 2Samuel 15:31, 34, 1Kings 12:8, Psalm 1:1, 33:10-11, Proverbs 20:5, and Isaiah 11:2.
d. Tachbulah (noun)—conveys the idea of “direction, guidance, or good advice.” (See Proverbs 11:14.)
e. Melak (Aramaic-noun)—means “advice.” (See Daniel 4:27.) The New Testament (NT) was originally written in Greek. The following Greek words are translated into the English word “counsel”:
a. Sumbouleuo (verb)—means “to counsel, to advise, or exhort.” The essence of the counsel (sumbouleuo) of Jesus to nominal believers in Laodicea was to turn from their materialistic self-complacency and open their hearts to true intimacy with Him (Rev. 3:18, 20). This word also means “to consult
together or to plot” as used in Matthew 26:4 and Matthew 28:12.
b. Boule (noun)—means “counsel, purpose, design, determination, or decree.” This word is used in Luke 7:30, Acts 2:23, Ephesians 1:11, and Hebrews 6:17. Noted Greek scholar Ken Wuest (1947) adds that boule means, “To desire, which desire comes from one’s reason…counsel to the effect that the soul might find a sure refuge in the Lord Jesus” (p. 123).
c. Bouleuo (verb)—means “to give counsel, to purpose, or to determine.” The idea of counsel being “advice or the act of giving advice” is a common thread tying most of these words together. Tachbulah, boule and bouleuo include “purpose” and “direction” to further expound the meaning. While good counsel includes advice-giving, Clinton and Ohlschlager (2002) encourage an approach that helps the client discover truth rather than simply telling them what the truth is. Drawing from Proverbs 20:5, they assert, “Truth drawn out of the client’s own life tends to be more deeply understood and more actively embraced, and it motivates and sustains the change process” (p. 204). Advice
The next word “advice” is translated from two different Hebrew words and a Greek word.
a. Dabar (noun) and ‘etsah (noun)—are Hebrew words that are also translated as “counsel” in the OT as described above.
b. Gnome (noun)—this Greek word means “view, intention, or reason.”
c. Webster’s dictionary (1983) defines advice as “counsel; an opinion offered as worthy to be followed in a particular situation” (p. 29). Plan
“Plan” and “purpose” are both translated from the Hebrew word machashabah (noun) which is found in Proverbs 16:3, Proverbs 20:18 and Jeremiah 29:11. In the New Testament, the Greek word prothesis (noun) means “purpose, a predetermination, or a setting forth” and is used in Romans 8:28; and 9:11.
Another word related to counseling is “instruction.” Examples from the Old Testament and New Testament are as follows:
a. Muwcar (noun)—Hebrew meaning “discipline or correction” as in Proverbs 19:20.
b. Paideia (noun)—this Greek word refers to the “training up” of children into adulthood. As it relates to believers, it is “instruction with the aim at increasing virtue.” A key passage where this word is used is 2Timothy 3:16. Wisdom
Wise counsel is non-negotiable for success in the therapeutic relationship. “Wisdom” is defined in the Hebrew and Greek below:
a. Chokmah (noun)—this Hebrew word also means “shrewdness or prudence.” There is a prophetic reference to the Messiah in Isaiah 11:2 indicating that He would have the “Spirit of wisdom (chokmah)” upon Him.
b. Sophia (noun)—Mounce (1993) defines this word as “wisdom, in general, knowledge, learning, science or enlightenment” (p. 419). This word can be found in James 3:16-17 where wisdom from God is contrasted with earthly, demonic wisdom.
Finally, forming a helping relationship is necessary for client change (Horvath & Luborsky, 1993, p. 561). The Hebrew words ‘ezrah and azar as well as the Greek words boetheia, sullambano, and epikouria, all basically mean “to help.” Psalm 60:11 concludes that help (‘ezrah) from man is useless. True help is only from the Lord. Christian counselors can boldly visit God’s throne of grace to receive grace for the right help (boetheia) to extend to clients (Hebrews 4:16).
As connecting dot-to-dots will form an image, combining these words together will provide a picture of counseling from a biblical worldview. In essence, there are two types of counsel: either godly or ungodly. Godly, wise counsel originates from God and accomplishes His purposes. Ungodly, unwise counsel is “earthly, sensual, demonic” and fulfills the plans of this present age (James 3:15-17). The goal of Christian counseling includes God’s eternal plan for souls to enter a relationship with Jesus and grow in Him. The priority of the counsel of Jesus is intimacy with Him above attaining material wealth and earthly satisfaction (Revelation 3:18, 20). In contrast, secular counseling has the temporal goal of human satisfaction and self-fulfillment (Clinton & Ohlschlager, 2002, p. 77).
Bufford (1997) considers the difference in goals as the most important factor distinguishing Christian from secular counseling (p. 120). For example, suppose a client’s unwanted pregnancy was causing distress in her life. A secular counselor would provide abortion as an option (Feldman, 2008, p. 57). A competent Christian counselor would assist the client to view issues through the lens of Scripture and would not suggest abortion as an option (AACC code of ethics, 2004, p. 7). Rather, the Christian counselor would supply other options such as adoption, para-church ministries, and other ideas to support the decision of carrying the baby to term.
Fulfillment, satisfaction, and peace are the by-products of godly counsel. When Moses appropriated the counsel of his father-in-law Jethro, he was able to manage his overwhelming responsibilities more efficiently and to have peace of mind (Exodus 18:19). Another illustration of counseling in Scripture is in 2Samuel 15. Ahithophel was once King David’s counselor. Ahithophel’s job was to provide advice to the king in order for him to make wise decisions in war plans and to understand the mind of the Lord in other practical matters.
Proverbs 20:18 (NKJV) instructs, “Plans (machashabah) are established by counsel (‘etsah); by wise counsel (tachbulah) wage war.” However, Ahithophel betrayed David by becoming Absalom’s counselor. Therefore, David prayed that Ahithophel’s counsel would be turned to foolishness. God honored David’s request, and the Lord’s counsel and purpose was accomplished (2Samuel 15-17). Ultimately, God’s counsel will stand forever, whereas the opinions and plans of man will pass away (Psalm 33:10-11). Biblical Words Related to Addiction
a. Yayin (noun)—means “wine.” Sometime after he departed from the ark, Noah became intoxicated by wine. Noah’s inebriated condition elicited a lack of inhibitory control because he “was uncovered within his tent” (Genesis 9:21 KJV). As a result, his son Ham apparently engaged in some sort of inappropriate behavior (Genesis 9:22-25). Lot’s daughters introduced wine into their plan to perform inappropriate behavior with their father (Genesis 19:32-35). These two examples present the negative side of wine abuse which coincides with sobering warnings in other passages (cf. Proverbs 20:1; 23:31-35). Scripture also displays wine as an illustration of joy. The Lord provides “wine that makes glad the heart of man” (Psalm 104:15a NKJV).
b. Oinos (noun)—In the NT, this Greek word means “wine.” Vine and Bruce (1981) expound, “The drinking of wine could be a stumbling-block and the Apostle enjoins abstinence in this respect, as in others, so as to avoid giving an occasion of stumbling
to a brother (Romans 14:21)” (p. 219). In contrast, Paul encourages Timothy to “no longer drink only water, but use a little wine for your stomach’s sake and your frequent infirmities” (1Timothy 5:23 NKJV).
a. Shekar (noun)—is an OT Hebrew word meaning, “strong drink or intoxicating liquor.” While performing priestly duties in the tabernacle, Aaron and his sons were forbidden to drink wine or strong drink under penalty of death (Leviticus 10:19).
b. Sikera (noun)—In the NT, this word means, “intoxicating beverage which is different from wine.” It was made of a mixture of sweet ingredients. John the Baptist did not drink wine or strong drink, but he was filled with the Holy Spirit from his mother’s
womb (Luke 1:15).
a. Teshuwqah—This OT word means “desire, longing, or craving.” God confronted Cain by personifying sin as a crouching lion ready to destroy him, who’s “desire [is] for you, but you should rule over it” (Genesis 4:7b NKJV).
b. Chamad—In Exodus, this Hebrew word meaning “desire, to take pleasure in, or to delight in” is translated as “covet,” being utilized in a negative sense. For example, the tenth commandment indicates that individuals are not to “covet” anything that belongs to a neighbor (Exodus 20:17).
c. Zeloo—This NT Greek word means “to be heated for or to be zealously sought after.”
This word is either used in a good or evil way, depending upon the context. For
example, James rebukes believers for desiring things with a sinful motive (James 4:2). In contrast, Paul exhorts believers to desire spiritual gifts (1Corinthians 14:1).
d. Epithumeo—This Greek word meaning “to long for, to lust after, a craving, to have a desire for, or to seek things forbidden” is presented in either a negative or positive light, depending upon the context. For example, Jesus revealed to His disciples that “many prophets and righteous men desired to see what you see” concerning the kingdom of God.
However, the usage of this word may also denote a sinful desire as in Romans when Paul disclosed that he became aware of his sinful nature when the commandment declared, “You shall not covet (epithumeo)” (Romans 7:7). The Bible appears to indicate that lust (epithumeo) and love are mutually exclusive (1John 2:15-17). Self-control
a. ‘Aphaq—This OT Hebrew word means “to hold back, refrain, or to restrain oneself.” Scripture instructs that a wise person will refrain from taking the popular path of the crowd and making sinful choices (Proverbs 1:8).
b. Egkrates—means “to exercise self-government, to conduct one’s self temperately, or to exhibit self-control.” Paul draws upon the competitive edge required to win in athletic events to inspire believers to exercise self-control as he describes, “Everyone who competes [for the prize] is temperate in all things” (1Corinthians 9:25a NKJV). Paul reveals that the ability to manifest self-control is the by-product of the work of God’s Spirit within a believer’s life (Galatians 5:23).
a. Nazar—means “to separate, consecrate, or to dedicate.” For example, men who had consecrated themselves to God with a Nazarite vow “must give up (nazar) wine and other alcoholic drinks” (Numbers 6:3a NLT). Though certain individuals may choose to take a vow that requires abstinence, Miller (1995) asserts, “Nowhere in scripture is abstinence from alcohol prescribed as a general rule” (p. 78). He cautions, “Alcohol is now known, for example, to damage brain tissue, and measures of brain impairment are correlated with amount even in the ‘moderation’ range” (Miller, 1995, p. 78).
b. Apexo—means “to hold one’s self off, refrain, or abstain.” The Bible teaches that God’s will is for believers to “abstain (apexo) from sexual immorality” (1Thessalonians 4:3). In fact, believers are commanded to “abstain from every form of evil” (1Thessalonians 5:22 NKJV). Scholars question whether a particular drug may be deemed as evil, requiring complete abstinence. Miller (1995) offers, “If a certain drug serves no good and useful purpose, and there is no known ‘safe’ level of use which does not cause harm (or risk of harm) to the person, then the use of that drug might be regarded in itself as sinful” (p. 81). He concludes, “As in the biblical view of alcohol, the appropriate use of chemicals is generally accepted in society” (p. 81). Comparing and Contrasting Biblical Views with Professional Views Addiction Defined
As the rudder steers a ship, a counselor’s theory guides the counseling process. To effectively steer the therapeutic session of clients with addictions, counselors must understand the dynamics of addiction. Addiction is defined as “self-destructive behaviors that include a pharmacological component. The most stringent application would limit the term addiction and the companion label of addict to individuals with a physiological dependence on one or more illegal drugs.” (DiClemente, 2003, p. 3). Addiction involves “an escalating pattern involving tolerance (e.g., seeming to be relatively unaffected by ordinary doses) and dependence (e.g., relying upon the drug to function or feel normal)” (Miller, 1995, p. 82). Still, over the past two decades, the definition of addiction has broadened to include “any substance use or reinforcing behavior that has an appetitive nature, has a compulsive and repetitive quality, is self-destructive, and is experienced as difficult to modify or stop” (DiClemente, 2003, p. 4).
Gambling, shopping, video games, internet pornography, negative view of body image, and even work may be included under the umbrella this broad definition of addiction (LaBerge, 2009, p. 13). The biblical definition of addiction coincides with the expanded definition, equating addiction with habitual self-absorbed behaviors which produce spiritual slavery. Welch (2001) clarifies,
Addiction is bondage to the rule of a substance, activity, or state of mind, which then becomes the center of life, defending itself from the truth so that even bad consequences don’t bring repentance, and leading to further estrangement from God. To locate it on the theological map, look under sin (p. 35). Etiology
Counselors with clients who present with symptoms of alcohol and drug addiction need to have competencies such as an understanding of addiction, treatment knowledge, how to appropriately integrate treatment modalities, assessment, screening, and diagnostic insight (Treatment Improvement Exchange, 2010). Scholars debate the origin of addiction, as observed by the variety of proposed models of addiction. The models of addiction include: the disease (genetic/physiological) model, coping/social learning model, personality/intrapsychic model, compulsive/excessive behavior model, and the conditioning/reinforcement model (DiClemente, 2003, pp. 9-18). The disease model posits that alcoholism is the direct result of genetic influences.
Yet, researchers demonstrate that “genetic factors account for approximately ‘half the risk for alcoholism.’” (Van Der Walde, Urgenson, Weltz, & Hanna, 2002, p. 146). Miller (1993) noted how a pure disease model does not give any role to the psychological factors in treatment (p. 132). Still, there appear to be two types of alcoholism which researchers present as evidence for a genetic influence. Van Der Walde et al. (2002) describe, “The first is a severe form of early-onset alcoholism, which often presents before age 21 and is characterized by a high density among first-degree relatives” (p. 146). The second form “does not appear until middle age and seems to be triggered by negative life events such as loss of a significant other or other environmental influences” (Van Der Walde et al., 2002, p. 146).
The social/environment model emphasizes an individual’s lack of coping skills in response to life’s stressors in conjunction with vicarious learning of maladaptive behaviors from others (DiClemente, 2003, p. 13). The coping model theorizes that individuals who are unable to deal with life stressors seek to escape through their addiction, relying upon the addiction for comfort (DiClemente, 2003, p. 13). Pangle (2010) observes, “There seems to always be an emotional distress associated with addiction. This emotional distress finds relief [or so the addict thinks] in numbing out and finding a temporary ‘escape’ from the pain involved” (personal communication, January 28, 2010).
Hester and Miller (2003) cite several coping skill deficits such as the “lack of adequate skills to regulate positive and negative mood states as well as to cope with social-interpersonal situations, including work, parenting, or marital relationships” (p. 213). Concerning the social learning aspect of this model, “several studies have shown that children and parents tend to exhibit similar drinking practices, indicating that observational learning plays some role in later alcohol use” (Ellis & Zucker, 1997, p. 222). Soberingly, Dawson, Goldstein, Chou, Ruan, and Grant (2008) demonstrate that “individuals who started drinking before 15 years of age were significantly more likely to experience the incidence of alcohol dependence and alcohol abuse in adulthood than those who delayed initiation of drinking until 18 or older” (p. 2155).
The personality/intrapsychic model seeks a connection between the intrapsychic conflicts within an individual or personality traits such as impulsivity, with substance abuse (DiClemente, 2003, pp. 11-12). The compulsive/excessive behavior model links “addiction with ritualistic compulsive behaviors like repeated hand-washing or cleaning rituals” (DiClemente, 2003, p. 16).
The conditioning/reinforcement model relies upon reinforcement theory to explain the etiology of addiction. For example, the intermittent schedule of reinforcement allotted for slot machines assures addictive usage for many patrons (Tavares, Zilberman, & El-Guebaly, 2003, p. 23).
The current literature appears to repudiate the view that physiological dependence is the key element that determines whether a person has an addiction. Instead, the emphasis has become the psychological component that develops and maintains addiction. Ksir et al. (2009) reveal, “Psychological dependence, based on reinforcement, is increasingly accepted as the real driving force behind repeated drug use” (p. 36). They indicated that tolerance and physical dependence do not play as a major role as psychological dependence (Ksir et al., 2009, p. 36).
Yet, Roberts and Koob (1997) contend that addiction is the by-product of the dual processes of reinforcement and neuroadaptation. They explain, “Working together, these factors appear to motivate the initial, short-term (i.e., acute) response to a drug and the establishment of the long-term (i.e., chronic) craving for the drug that characterizes addiction” (p. 102).
It has been argued that the five models of addiction described above do not address the etiology and the treatment strategy of the addiction in a comprehensive way. DiClemente (2003) asserts, “There is also no single developmental model or singular historical path that can explain acquisition of and recovery from addictions” (p. 19). For instance, the prevalent view concerning alcoholism coincides with the disease model “which someone either ‘has’ or does not have and which has an inevitable progression to more and more drinking, then the only acceptable treatment goal is total abstinence” (Ksir et al., 2009, p. 430). The etiological view directly impacts treatment as seen with Alcoholics Anonymous (AA) which subscribes to the disease model, having total abstinence as the goal (Ksir et al., 2009, p. 430). Evidence-based research also demonstrates effectiveness of psychosocial approaches and indicates that the disease model is too limited in its perspective and application (Miller, 1993, p. 132). Still, Miller (1993) contends, “Dispositional disease views have remained strangely intermingled with moralistic attitudes toward people who are alcoholic,” seeing alcoholics as prone to lie and deny their problem (p. 131).
Therefore, this researcher leans more toward a biopsychosocial model which allows for more of a comprehensive view of the etiology and an eclectic approach to treatment. That is, “a descriptive model based on continua of severity and an etiologic model encompassing host, agent, and environmental factors” (Miller, 1993, p. 135). Instead of viewing alcoholism as a disease like diabetes (you either have it or you don’t), this researcher favors using the analogy of having hypertension which is “genetically influenced yet quite responsive to psychosocial factors” (Miller, 1993, p. 134).
Concerning the “bio” part of the biopsychosocial view, Scripture seems to endorse certain aspects of the disease model. However, the sickness ultimately appears to be sin (Isaiah 1:5-6). That is, an addiction such as alcoholism is the symptom of the sin disease (Galatians 5:21). Jesus refers to the disease model as an illustration of humanity’s dilemma and combines this “sin disease model” with what seems to be the moral model with the call to repentance—which is the treatment (Mark 2:17). The “psycho” coincides with where Scripture instructs believers to “renew” their minds, identifying the association between thought and behavior (Ephesians 4:23). The “social” element is observed in how Paul warns, “Do not be misled: ‘Bad company corrupts good character’” (1Corinthians 15:33 NLT). For example, a person ought not hang out at the bar, or he will most likely drink.
The Scriptural etiological view of addiction begins with an individual’s concept of self, God, and other relationships. For example, an addict could be viewed as a person who is unwilling to come to terms with his inaccurate view of self, God, and other relationships. In contrast, a psychologically healthy person is someone who has an accurate understanding of self and does not focus on self. McMinn (1996) instructs that “To be healthy, we need to move beyond a preoccupation with self” (p. 46). An unhealthy self-concept produces detrimental results. At one extreme, Nebuchadnezzar’s inflated view of self led to blind rage and insanity (Daniel 3:18-19; 4:30-34). On the other side of the spectrum, McMinn (1996) described a man with a low view of self which brought forth destructive behaviors such as drinking alcohol excessively (p. 47). A healthy view of self does not cause a person to be lifted up with pride nor to be brought down to a permanent condition of wallowing in utter self-loathing.
Isaiah developed a balanced sense of self when he gained an accurate vision of God. Isaiah’s encounter with God produced genuine brokenness, forgiveness, and a sense of godly competence to fulfill the high call of God (Isaiah 6:1-8). The primary element that contributed to Isaiah’s healthy sense of self was his open recognition of need. McMinn (1996) asserts that “there is only one way to spiritual health, and that requires us to recognize that we need God” (pp. 48-49). Therefore, people who have a healthy sense of self recognize their own spiritual poverty and desperate need for God. The subjective, experiential sensing of “need” for God is an appropriate craving or “thirst.” Jesus pointed to Himself as the only One who truly satisfy this thirst (John 4:13-14). Assessment
A person who describes an egg as a two-fold object composed of shell and egg white is missing the yolk, therefore lacking the complete definition. Similarly, clinicians who do not include spiritual assessment in gathering data will lack a holistic, “whole person” perspective of their clients. For example, Hodge (2005) asserts that “human beings are an integrated entity, consisting of body, soul, and spirit” (p. 316). This triune understanding of a human being’s composition is consistent with a biblical worldview (1Thessalonians 5:23). Still, it is not solely Christian clinicians who recognize the need to include a client’s spiritual background within the counseling setting. Hodge (2006) reveals, “Growing consensus exists that spiritual assessment is an important aspect of holistic service provision” (p. 317).
Moreover, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which is the largest health care accrediting body in the United States, “now requires the administration of spiritual assessment” (p. 317). A majority of clients have also expressed the desire to incorporate spirituality within the therapeutic setting (Hodge, 2006, p. 317). Spirituality is frequently at the core of how clients develop their worldview and coping skills (Hodge, 2005, p. 314). This understanding is vital for developing effective strategies with clients addicted to alcohol and drugs.
Comprehensive, qualitative spiritual assessment methods include spiritual histories, spiritual lifemaps, spiritual genograms, spiritual ecomaps, and spiritual ecograms. Spiritual histories describe a format that uses questions “to explore spiritual and religious themes in the context of an empathic dialogue” (Hodge, 2001, p. 205). For example, the counselor presents open-ended questions with a spiritual theme to encourage clients to verbally share their spiritual narrative or story. Examples of questions a clinician may use include “When and in what ways do you feel close to the Divine?” and “How is God involved in your problems?”
Two other assessment tools commonly used to identify the severity of alcohol problems are “the Alcohol Use Disorders Identification Test (AUDIT) and the CAGE. These instruments are listed in the NIAAA Guide and are available in computerized versions” (Hester & Miller, 2006, p. 37). These and other screening tools offer benefits such as providing “personalized feedback to clients in a timely and visually engaging manner” as well as “specific recommendations for change, based on the results of the assessment and other empirical evidence (Hester & Miller, 2006, p. 37). Corresponding to the transtheoretical model (TTM), “a 12-item Readiness to Change scale has been developed as an efficient measure of three stages from the transtheoretical model: precontemplation, contemplation, and action” (Hester & Miller, 2003, p. 100). Diagnosis
Before a mechanic can fix a car with engine trouble, he first must identify the problem. Likewise, appropriate diagnosis precedes effective counseling. According to the American Psychiatric Association (APA) (2000), the DSM-IV-TR describes the diagnosis for 303.90 Alcohol Dependence as “indicated by evidence of tolerance or symptoms of Withdrawal. Especially if associated with a history of withdrawal, physiological dependence is an indication of a more severe clinical course overall” (p. 213). The diagnosis of 305.00 Alcohol Abuse “requires fewer symptoms and, thus, may be less severe than Dependence and is only diagnosed once the absence of Dependence is established” (APA, 2000, p. 214).
Instead of being viewed categorically, that is, either a person has an alcohol disorder or not, researchers suggest that problems or addictions be viewed as being in different dimensional phases. This perspective corresponds to the psychosocial problem theory. Maddux and Winstead (2008) explain, “Psychosocial problem theory sees the dimensional responses as the very problems for which people need help, and dimensional measures as sufficient to evaluate, communicate about, and remedy them” (p. 143). The criticism that disorder theory has received is because “disorder theory prescribes shifting the focus from concrete problem dimensions to abstract mental disorders” (Maddux & Winstead, 2008, p. 143). This is not to say that categorizing disorders does not have benefits. Vieta and Suppes (2008) expound,
Dichotomies are useful for education, communication, and simplification; unfortunately, simplicity is useful, but untrue, whereas complexity is true, but useless. In clinical practice, we may use current classifications, such as DSM-IV, as categorical backgrounds that may help in establishing treatment and prognosis (p. 165). Consequences
Researchers have demonstrated that “alcohol use can increase adolescents’ exposure to risky situations, such as driving while intoxicated, engaging in unprotected sex, and confronting violent exchanges” (Hester & Miller, 2003, p. 83). Price and Emshoff (1997) reveal, “Children of alcoholics (COA’s) are at increased risk for a wide range of behavioral and emotional problems, including addiction to alcohol and other drugs (AOD’s), depression, anxiety, school failure, and delinquency” (p. 241).
A major reason for the higher risk of problems in COA’s is because “cross-generational transmission of alcoholism increases in likelihood to the extent that alcoholism invades the family system and disrupts the enactment of family rituals; that is, patterns of behavior that give identity and meaning to the family” (Jacob, 1992, p. 323). Hester and Miller (2003) assert, “Persons drinking three to four drinks per day have a two- to threefold risk for accidents, stroke, liver disease, cancer, and hypertension” (p. 65). Scripture asserts that “there is a way that seems right to a man, But its end is the way of death” (Proverbs 14:12 NKJV). Intervention Strategies
Researchers assert that clinicians working with clients addicted to alcohol need to “become more comfortable with…brief therapy intervention technique, and motivational interviewing” (Hester & Miller, 2003, p. 69). Motivational interviewing, which “aims to increase a patient’s motivation to change, has been found effective in controlled clinical trials” (McCarty, Edmundson, & Hartnett, 2006, p. 8). The stages of change according to the transtheoretical model (TTM) include precontemplation, contemplation, preparation, action, and maintenance (DiClemente, 2003, p. 27).
MI is helpful in addressing the client’s ambivalence and tipping the decisional balance toward change (Hester & Miller, 2003, p. 65). For example, MI has helped motivate clients to move from the precontemplation stage to the contemplation stage or from the preparation stage to the action stage. Four key factors that define MI include expressing empathy, developing discrepancy, rolling with resistance, and supporting self-efficacy (Miller & Rollnick, 2002, pp. 36-41). For example, the counselor conveys acceptance by incorporating listening skills such as reflective listening, paraphrasing, and clarifying.
Empathy and acceptance promote an atmosphere conducive for change. To develop discrepancy, the client “rather than the counselor” is led to “present the arguments for change” (Miller & Rollnick, 2002, p. 39). Empathy is characteristic of the person-centered approach and is considered “the most powerful determinant of client progress in therapy” (Corey, 2005, p. 173). Empathy disarms clients’ defenses and promotes trust within the therapeutic relationship. Empathy “involves demonstrating the act of listening to the subject and understanding the individual’s situation and the emotional reaction to it with the purpose of establishing a basic trust relationship” (Regini, 2004, p. 2).
Without it, there will be no change. In fact, research has shown that the model of therapy is not what determines the effectiveness of therapy, but the quality of the therapeutic relationship. McKergow and Korman (2009) assert, “More important are the therapeutic alliance as seen by the client, allegiance of the therapist to their model of choice, placebo effects, and general therapist competence” (p. 46). Person-centered theory presumes that the quality of the relationship between the therapist and client is all that determines change
(Kirschenbaum, 2004, pp. 116-117).
Research has shown that the key predictor in achieving a successful outcome in treatment is a strong therapeutic relationship between the clinician and client (Jennings & Skovhalt, 1999, p. 4). If clinicians do not establish trust in the first phase of the working alliance with their client, their client will be less likely to proceed to the next level that includes “shared responsibility for working out treatment goals” (Horvath & Luborsky, 1993, p. 563). Clinton and Ohlschalger (2002) insist that trust is vital “…for without it the client too easily backs away from the difficult challenges inherent to change” (p. 205). Trust is established when the client perceives the counselor as caring, sensitive, sympathetic, and helpful (Horvath & Luborsky, p. 564). Patients who do improve with medication often become less consistent with taking their medications over time. A strong alliance has been shown to help in this area. Strauss and Johnson (2006) reveal that “patients who reported stronger alliances with their providers reported more positive attitudes about medication and stigma. (p. 220).
Spiritual, psychological, and emotional health is interwoven within the fabric of loving relationships. The author of Hebrews encourage believers to “consider one another in order to stir up love and good works, not forsaking the assembling of ourselves together, as is the manner of some, but exhorting one another, and so much the more as you see the Day approaching” (Hebrews 10:24-25 NKJV). There are necessary times for solitude but disaster awaits people who completely cut themselves off from authentic relationships. Solomon instructs, “A man who isolates himself seeks his own desire, he rages against all wise judgment” (Proverbs 18:1 NKJV). Therefore, clients are encouraged to join a small group Bible study, a men’s group, a women’s group, a cancer support group, or another group conducive to a client’s need.
Solutions-focused brief therapy (SFBT) employs rapport-building techniques such as active listening. The counselor seeks to understand what the client wants through actively listening and echoes back the past, present, and future desires of the client. In addition, active listening entails paraphrasing, summarizing, and asking questions. SFBT has been useful in walk-in sessions. Clinical interviewing techniques are “designed to move clients away from focusing primarily on the problem and toward a focus on solutions. Some of these ideas include attending to exceptions to the problem (already existing periods when the problem is not occurring)” (Slive, McElheran, & Lawson, 2008, p. 14). Other treatment strategies for clients struggling with alcohol dependence and abuse include psycho-education, family therapy, behavior modification, detoxification, and 12-step programs such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) (Kanel, 2007, p. 176).
Hester and Miller (2003) demonstrate, “Patients attending AA were significantly more likely to be abstinent than those not attending” (p. 182). They also provide a summary of treatment strategies by order of their effectiveness such as coping skills treatment (CST), cue exposure treatment (CET), community reinforcement approach (CRA), and community reinforcement and family training (CRAFT) (Miller & Hester, 2003, pp. 218, 229-232, 237-240).
Brewer (2008) presents an integrative Christian counseling grid called METAMORPH. He delineates that “METAMORPH integrative Christian counseling grid represents an eclectic approach to counseling that seeks to responsibly draw upon a plethora of counseling theories within the context of a Christian worldview” (Brewer, 2008). Truth drawn out from an individual’s life has the tendency to be more easily apprehended and embraced (Proverbs 20:5). For example, Brewer (2008) integrates choice theory techniques with exploratory questions such as: “What do you want? What are you doing to get what you want? How is it working for you? Is it the right thing to do?”
When Adam and Eve were hiding in the garden, God asked them “Where are you?” God knew where they were, but He wanted them to become self-aware and to consider turning back to Him (Genesis 3:9-13). In like manner, Jesus asked His disciples important questions (Matthew 16:13, 15).
Concerning pharmacotherapy, prescribing medications for mental disorders has been a controversial practice especially in Christian circles. This researcher has been quite wary in the past about any type of drug therapy, because God has “given to us all things that pertain to life and godliness” through His divine power (2Peter 1:3a NKJV). In addition, Scripture is sufficient to help believers become complete and mature, “equipped for every good work” (2Timothy 3:17b NKJV). The two previous biblical references did not include mention of the need for medications. Yet, it is interesting that soon after, Paul describes one of the requirements for godly leadership as “not given to wine,” which means to not abuse alcohol or to not be addicted to wine. Two chapters later he instructs Timothy to personally use wine for a medicinal purpose (1Timothy 3:3a; 5:23 NKJV).
This researcher currently holds the view that certain drugs including medications for brain chemical imbalances were given through God’s guidance to benefit humanity. However, just as there is a danger that wine may be abused and lead to tragic consequences, these medications have the potential of being abused. Clinton and Ohlschlager (2002) teach, “They [psychiatric medications] have tremendous potential to help people with problems that can destroy their lives psychologically, medically, and spiritually. However, they must be used with care and at the discretion of someone who is skilled in their administration” (p. 152).
Drug therapies address the neurobiological dysfunctions which impair emotions and behavioral functioning. Medications are not necessarily the “silver bullet” in solving all the issues which challenge individuals any more than wine was the cure-all for Timothy’s problems. Rather, they may help promote enough emotional stability for a client to be able to receive input regarding other issues. An example of a medication that has been successful in the treatment of alcohol addiction is naltrexone, which “is an opiate-antagonist medication. Clinical trials suggest that naltrexone contributes to reductions in the frequency of drinking and severity of relapse among alcohol-dependent patients” (McCarty et al., 2006, p. 7). Personal Application
As the rudder steers a ship, a counselor’s theory guides the counseling process. This researcher believes that a comprehensive counseling theory begins with a biblical worldview that evaluates psychological contributions, human nature, and the systems that shape the human personality, and view of addiction through the lens of Scripture. Psychology often limits its focus to the study of the soul. The word “psychology” is a combination of the words -ology and psyche.
The suffix -ology means “the study of.” The Greek word psyche in the Bible means “a living soul,” and it is also defined as “the seat of the feelings, desires, affections” (Blue Letter Bible, 2010). Therefore, psychology is the study of one of God’s works, the human soul. Theology derives meaning from His word, the Bible. Averbeck (2006) proposes that the “double knowledge” of psychology (knowledge of the human person) and biblical theology (the knowledge of God) is necessary. He expounds, “Neither one is complete in itself; both need the other…True wisdom is bringing the knowledge of God and people together in the midst of the mess which we are and in which we live. This is what the Bible and counseling are really all about” (p. 111). Therefore, this researcher seeks to integrate theology and psychology into his understanding of addiction.
This researcher works in a psychiatric hospital setting. Alcohol dependence and abuse in particular is common within the patient population. Jeannette Sapp, a clinician at the hospital discloses, “Alcohol is the drug of choice for many patients because it is available, legal, and relatively inexpensive. Many patients self-medicate their particular disorder” (personal communication, February 16, 2010).
The stages of change are going to become hospital policy concerning patient treatment. The supervisor has been encouraging clinicians to consider the specific stage of change each patient they are working with is in. This is a necessary step since each stage of change has different tasks which require appropriate corresponding interventions (DiClemente, 2003, p. 240). DiClemente (2003) asserts, “The best way to mirror the process of change is to have a dynamic treatment protocol that can respond to being stuck at various stages as well as to movement through the stages of change” (p. 250).
It is helpful to understand that “addictions are understood as learned habits that once established become difficult to extinguish even in the face of dramatic, and, at times, numerous negative consequences” (Jenkins, n. d.). Since addictions are learned habits which develop through the stages of change, they can be unlearned and replaced with healthy and helpful habits as the individual progresses through the stages of change.
As applied to believers, Christians are to deal with ambivalence concerning the “tug of war” between sin and the new nature, and to move along the stages, becoming transformed into the image of Christ from glory to glory by God’s Spirit (Romans 7:7; 2Corinthians 3:18). Clinton and Ohlschlager (2002) clarify, “The effective Christian clinician will be a principled, biblically informed, and responsible eclectic who knows how to fit the right therapy with the right client at the right time and the right stage of living” (p. 176).
Christian counselors are to model the divine Counselor. Jesus, the “Wonderful, Counselor” (Isaiah 9:6b), has all the qualities for promoting effective client outcomes: genuine compassion, ability to comfort, ability to challenge, and a provider of sanctuary for the client. Jesus said that “everyone who is perfectly trained will be like his teacher” (Luke 6:40b). Christian counselors know they will become like the best counseling teacher as they learn from the Master Himself (2Corinthians 3:18). Jennings and Skovhalt (1999) identified and defined the key characteristics of master therapists. They also gave credit to studies that describe effective therapists who have attributes such as compassion, sensitivity, and commitment to their clients’ well-being.
These qualities describe love. Clinton and Ohlschlager (2002) insist that “the most important counseling tool is you” (p. 67). Tripp (2002) insists, “God never intended us to simply be objects of His love. We are also called to be instruments of that love in the lives of others” (p. 18). The goal of this writer is to become a competent and effective counselor. The starting point of reflecting His love is allowing Jesus to be the “first love.” The AACC code of ethics (2004) which states, “Christian counselors are dedicated to Jesus Christ as their ‘first love’” (p. 5), for He alone can truly equip and empower a person to be a tool filled with the agape love everyone needs (John 15:5; Acts 1:8).
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