Fundament

als of
Addiction
Fundament
als of
AddictionA
Practical Guide
for Counsellors
4th Edition—formerly published as Alcohol & Drug Problems

Edited by Marilyn Herie and W. J. Wayne Skinner

Foreword by Gabor Maté
Library and Archives Canada Cataloguing in Publication

Fundamentals of addiction: A practical guide for counsellors / edited by Marilyn Herie

and W.J. Wayne Skinner; foreword by Gabor Maté. —4th ed.

Revision of: Alcohol & drug problems.

Includes bibliographical references and index.

isbn 978-1-77114-147-5 (print)

isbn 978-1-77114-148-2 (pdf)
isbn 978-1-77114-149-9 (html)
isbn 978-1-77114-150-5 (epub)

1. Alcoholism counseling. 2. Drug abuse counseling. 3. Alcoholism counseling—

Canada. 4. Drug abuse counseling—Canada. I. Herie, Marilyn, 1963–, editor of
compilation. II. Skinner, W.J. Wayne, 1949–, editor of compilation. III. Centre for
Addiction and Mental Health. IV. Title: Fundamentals of addiction.

RC564.15.A42 2013 362.29'186 C2013-902054-3 C2013-902055-1

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v

Contents

ix Preface
Marilyn Herie and Wayne Skinner

xiii Foreword
Gabor Maté

SECTION 1: THE BASICS

3 1 Biopsychosocial Plus: A Practical Approach to Addiction and
Recovery Wayne Skinner and Marilyn Herie

29 2 A Client Perspective
Cheryl Peever
 43 3 Diversity and Equity Competencies in Clinical Practice
Janet Mawhinney

63 4 Working within a Harm Reduction Framework

David C. Marsh and Dale Kuehl

83 5 Motivational Interviewing
Marilyn Herie and Wayne Skinner

117 6 Neurobiology of Substance Use Disorders and

Pharmacotherapy Rachel A. Rabin and Tony P. George

133 7 Physical Effects of Alcohol and Other Drugs

Meldon Kahan

SECTION 2: CLINICAL INTERVENTIONS

165 8 Screening and Assessment Practices
Linda Sibley

193 9 Brief Interventions for At-Risk Drinking

John A. Cunningham and David C. Hodgins

205 10 Relapse Prevention

Marilyn Herie and Lyn Watkin-Merek
vi

239 11 Tobacco Interventions for People with Alcohol and Other Drug
Problems Peter Selby, Megan Barker and Marilyn Herie

275 12 Opioid Addiction

Rosanra Yoon

293 13 Family Pathways to Care, Treatment and Recovery

Wayne Skinner, Toula Kourgiantakis and Caroline O’Grady

321 14 Mutual Help Groups

John Kelly, Keith Humphreys and Julie Yeterian

349 15 A Digital Future: How Technology Is Changing Addiction

Recovery Sylvia Hagopian, Anne Ptasznik, Paul Radkowski and
Monique Peats

SECTION 3: SPECIAL ISSUES AND CONSIDERATIONS

367 16 Concurrent Disorders
Andrea Tsanos

399 17 Working with Clients Who Have Histories of Trauma

Tammy MacKenzie, Robin Cuff and Nancy Poole

419 18 Acquired Brain Injury and Fetal Alcohol Spectrum Disorder:

Implications for Treatment
Carolyn Lemsky and Tim Godden

461 19 Treating Addictions in Correctional Settings

Andrea E. Moser, Flora I. Matheson, Brian A. Grant and John R. Weekes

481 20 What if it’s Not About a Drug? Addiction as Problematic Behaviour

Nina Littman-Sharp, Kathryn Weiser, Lisa Pont, Janis Wolfe and
 Bruce Ballon

SECTION 4: SPECIFIC POPULATIONS

523 21 Working with Women
Nancy Poole, Susan Harrison and Eva Ingber

549 22 Working with Youth and Their Families

Gloria Chaim and Joanne Shenfeld

581 23 Older Adults and Substance Use

Jennifer Barr and Virginia Carver

611 24 Colonization, Addiction and Aboriginal Healing

Peter Menzies

635 25 People with Diverse Sexual Orientations and Gender Identities

Who Have Substance Use Concerns
Jim Cullen, Dale Kuehl and Nick Boyce
vii

SECTION 5: PROFESSIONAL PRACTICE AND SYSTEM ISSUES

675 26 Legal Issues
Robert M. Solomon and Sydney J. Usprich

703 27 Tips for Testifying in Court

Sydney J. Usprich, Robert M. Solomon and Cate Sutherland

715 28 The Essential Ingredients for Clinical Supervision

Kirstin Bindseil, Marion Bogo and Jane Paterson

733 29 Care Pathways for Healing Journeys: Toward an Integrated System

of Services and Supports
Rebecca Jesseman, David Brown and Wayne Skinner

755 About the Editors

756 About the Authors

767 Index
ix

Preface
Marilyn Herie and Wayne Skinner

Addiction treatment is often seen as a “black box” by clients and helping

professionals alike. A popular perception of the process is something like this: 1)
person hits “bottom” or is in the hot seat of an “intervention”; 2) person enters
“rehab” (i.e., inpatient addic tion treatment); 3) person gets “treated”; 4) person is
“cured” (or drops out); 5) repeat as necessary. Although this portrayal of addiction
and its treatment can make for a gripping storyline in film, television or fiction, it
doesn’t begin to reflect the reality of our current
 scientific understanding and the diversity of evidence-based approaches to
addictions. The fact is, not all people need or want specialized addiction treatment.
Many clients are best served in community settings where they can receive
services that are integrated into their overall care. The skills required to respond to
addiction map well onto good clinical practice: listening to our clients with
compassionate empathy, fostering trust and a positive therapeutic alliance, and
respecting the innate autonomy of the people we serve. This book can be used by
virtually any practitioner across the spectrum of care as a practical guide to helping
clients overcome the harmful, sometimes devastating, effects of addiction.
For this fourth edition of Alcohol & Drug Problems, we decided on a new title,
Fundamentals of Addiction, to reflect advances in the field extending beyond
psychoactive drug use to include behavioural or “process” addictions. This iteration
continues to build on a rich legacy of previous editions in providing practitioners
with essential information and treatment models for diverse client populations.
As our knowledge and understanding of addictions increase, so does the
complexity of the chapters in this edition. The content is divided into five sections.
Section 1: The Basics lays the foundation and provides the theoretical framework
for the book as a whole. The chapters cover a client perspective, diversity and
equity competencies, harm reduction, motivational interviewing and the
neurobiological and physical aspects of substance use. Section 2: Clinical
Interventions examines screening and assessment, as well as a range of
interventions and approaches, including brief interventions; relapse prevention;
specific knowledge and skills relating to tobacco dependence, opioid misuse and
dependence; family involvement; mutual support; and online interventions in the
“digital age.” Section 3: Special Issues and Considerations presents practical
issues around treating people with concurrent disorders, trauma and
neurobiological impairments, and discusses considerations for working with people
in correctional settings and those with behavioural addictions. Section 4: Specific
Populations examines diversity as it relates to women, youth, older adults,
Aboriginal people and people with diverse sexual orientations and gender
identities. Finally, Section 5: Professional Practice and System Issues shares
invaluable knowledge about ethical issues in clinical practice, legal issues and tips
for
x Fundamentals of Addiction: A Practical Guide for Counsellors

testifying in court, clinical supervision, and care pathways in an integrated addiction

treatment system.
One challenge—as well as an advantage—of edited books is the diversity in
authors’ voices and writing style. We value this diversity, but also sought a
consistent structure in order to give this edition a more cohesive look and feel and
to amplify the practical nature of the information. To that end, most chapters begin
with a short case example and conclude with key practice tips and recommended
print and web resources. We, and sometimes the authors, struggled somewhat
with the case examples. On one hand we wanted to provide real-world anchors for
the content; on the other hand, no individual story can represent the rich complexity
of human experience. These composite cases are offered in the spirit of each
person being “like all others, some others, and no others” (to paraphrase Henry A.
Murray and Clyde Kluckhohn in their 1953 book Personality in Nature, Society, and
Culture).
This fourth edition has been wholly revised and updated, and as such has
been a considerable undertaking. We wish, first of all, to thank our authors, who
have contributed their expertise and many hours of their time with one goal in mind
 —to assist you in your important work of reducing the harm related to addictions.
We are grateful to Dr. Gabor Maté for contributing the provocative foreword that
challenges counsellors to consider early childhood experiences and trauma as
significant risk factors for addictions, rather than the more commonly held and
“misguided” view that genetics plays a major role in our predisposition to addiction.
We also wish to thank our reviewers for their careful reading of early drafts,
and for their thoughtful and constructive feedback. In alphabetical order: Branka
Agic, Paul Antze, Kirstin Bindseil, Myra Borenstein-Levy, Nick Boyce, Nicola
Brown, Amer Burhan, Diana Capponi, Walter Cavallieri, Stephanie Cohen, Robin
Cuff, Debbie Ernest, Margaret Flower, Cynthia Geppert, Christopher Hadden,
Michelle Hamilton-Page, Patricia Hays, Dave Hedlund, Christian Hendershot,
Kathryn Irwin-Seguin, Linda Jackson, Mattias Kaay, Milan Khara, Akwatu Khenti,
Amy Krentzman, Sharon Labonte-Jaques, Wiplove Lamda, Lynn Lavallée, Bernard
Le Foll, Michael Lester, Saul Lev-Ran, Myra Levy, Susan Morris, Ellie Munn, David
North, Anna Palucka, Tom Payette, Mike Prett, Dan Reist, Núria Ribas, Janine
Robinson, Lori Shekter-Wolfson, Debora Steele, Valerie Temple, Andrea Tsanos,
Cristine Urquhart, Paulette West, Jodi Wolff, Martin Zack, Laurie Zawertailo and
Sarah Zemore.
We are also immensely grateful to Julia Greenbaum, who co-ordinated the
production of this fourth edition with grace, patience and persistence; Diana Ballon,
for her masterful editorial skills; Hema Zbogar, for her laser-like copy editing
precision; and Nancy Leung, for the simplicity and elegance of the book’s design.
CAMH’s library staff helped many of the authors access the most current research
on their topics, for which we are most grateful. We also wish to acknowledge Betty-
Anne Howard, who provided the initial inspiration for this book, the first edition of
which was published in 1993. To these contributors and many others behind the
scenes, thank you for your help in bringing this project to completion.
xi Preface

With this book we have tried to shine a light into the “black box” of addictions,
with a goal of increasing treatment capacity and access to services by those in
need. To our many readers in clinical practice, we hope this guide continues to be
valuable in your professional development and in your day-to-day work with clients.

We invite you to join our blog at

http://knowledgex.camh.net/amhspecialists/specialized_ treatment. This forum will
provide an opportunity to promote and generate dialogue around various addiction
issues informed by your reading of this book.

Foreword
Gabor Maté

What is addiction, really? It is a sign, a signal, a symptom of distress. It is a

language that tells us about a plight that must be understood.

—Alice Miller, Breaking Down the Wall of Silence

This fourth edition of Alcohol & Drug Problems—now the Fundamentals of

Addiction— marks an important movement forward in the understanding of
 addiction. In taking notice of the behavioural addictions, it recognizes that the
specific target of the addictive drive does not define the nature of addiction.
At the heart of addiction is what I’ll refer to as the universal addiction process,
which involves the same emotional dynamics no matter what the form of the
addiction. These emotional dynamics are just as true of an addiction to a
substance—whether ingested, inhaled or injected—as they are of compulsive
Internet use, shopping, gam
bling, sexual roving or any number of behaviours that may even be valued and
rewarded by society, such as excessive involvement with work, the acquisition of
wealth or the attainment of power. More surprisingly, we now know that all
addictive manifestations, substance-related or not, use and activate the same brain
circuits and neurochemicals. These target behaviours may vary in their form,
severity and consequences, but they are all expressions of a deeper and complex
universal process whose templates are grounded in human psychological needs,
emotional drives, neurophysiological functions, social and cultural influences and, if
one may be permitted to utter the word in a scientific publication, in the spiritual
nature of human beings.
According to the American Society of Addiction Medicine ([ASAM], n.d.), addic tion
is “a primary, chronic disease of brain reward, motivation, memory and related
circuitry . . . reflected in an individual pathologically pursuing reward and/or relief by
substance use and other behaviors” (p. 1). Considering addiction to be a “primary”
dis ease implies that the addiction is unrelated to any previous condition or injury.
Yet to speak of addiction as a primary disease is to ignore the reality that an
ante cedent injury—if not of a physical nature, then at least of an emotional one—
usually precedes the addiction. Emotional more than physical injury leads to long-
term psycho logical and neurobiological consequences predisposing to addiction.
People are quite resilient to surviving physical injury, much less so when that injury
is psychic and occurs in the child’s nurturing environment during the developing
years.
When it comes to etiology, the ASAM, like much of addiction medicine
practice, considers the major influence to be genetics. In fact, it asserts that
“genetic factors account for about half of the likelihood that an individual will
develop addiction”
xiv Fundamentals of Addiction: A Practical Guide for Counsellors

(ASAM, n.d., p. 5). Yet this assertion is not supported by scientific evidence.
Rather, trauma, the most important risk factor involved in the neurobiology and
psychology of addiction, is listed very low among the ASAM’s list of etiologic
circumstances. It may be that, as a physician colleague in San Francisco once said
to me, “The medical profession is traumaphobic.”
For 12 years, I worked in Vancouver’s Downtown Eastside, known as
Canada’s poorest postal code and notorious as North America’s most concentrated
area of drug use. Every female patient I ever interviewed offered or endorsed a
history of sexual abuse in childhood, and all patients, male or female, had endured
childhoods of abuse, neglect, abandonment and trauma. If this link to abuse had
been something only I observed, one could easily dismiss it as subjective and
unreliable. But large-scale population surveys have found a similar association.
Studies repeatedly find that extraordinarily high percentages of addicts have
experienced childhood trauma, including physical, sexual and emotional abuse.
Dube and colleagues (2003) remarked that the prevalence of childhood trauma
among addicts was “of an order of magnitude rarely seen in epidemiology and
public health” (p. 568). Their research, the renowned Adverse Childhood
 Experiences (ACE) study, looked at the incidence of 10 categories of painful
circumstances, including family violence, parental divorce, family substance use
problems, death of a parent and physical or sexual abuse, in thousands of people.
The correlation between these experiences and substance use problems later in
life was then calculated. For each adverse childhood experience, the risk for the
early initiation of substance use problems increased between two- and four fold.
People with five or more such experiences had a seven to 10 times greater risk for
substance use problems than those with no such experiences.
Dube and colleagues (2003) concluded that nearly two-thirds of injection drug
use can be attributed to abusive and traumatic childhood events. In clinical practice
with a heavily addicted population, I believe childhood trauma percentages may run
close to 100 per cent. Although not all addicts have been subjected to childhood
trauma, just as not all severely abused children grow up to be addicts, there is no
doubt that most hard
core injection users have experienced childhood trauma.
According to a 2002 review by Harold Gordon at the U.S. National Institute on
Drug Abuse:

The rate of victimization among women substance abusers ranges from

50% to nearly 100%. . . . Clinic populations of substance abusers are found
to meet the [diagnostic] criteria for post-traumatic stress disorder. . . . Those
experiencing both physical and sexual abuse were at least twice as likely to
be using drugs than those who experience either abuse alone. (pp. 116–
117)

Alcohol consumption has a similar pattern: people who had suffered sexual
abuse were three times more likely to begin drinking in adolescence than those
who had not. For each emotionally traumatic childhood circumstance, there is a
two- to threefold
xv Foreword

increase in the likelihood of early alcohol abuse. Dube and colleagues (2006)
concluded, “Overall, these studies provide evidence that stress and trauma are
common factors asso ciated with consumption of alcohol at an early age as a
means to self-regulate negative or painful emotions” (p. e8).
The salient psychological template for substance use or behavioural addiction
is unre solved emotional pain. All addictive manifestations, substance-related or
not, are an attempt, in the words of the former heroin-addicted Rolling Stones
guitarist Keith Richards (2010), to seek oblivion: “The contortions we go through,”
the legendary musician writes in his autobi ography, “just not to be ourselves for a
few hours.” And why? Because the emotional burden is too much to bear. It is not a
linguistic accident that we speak of heavy drinkers as “feeling no pain.” Abuse,
neglect and even a simple lack of attunement owing to parents’ stress will make
children feel inadequate, empty and uncomfortable with themselves. The greater
the environmental stress, as in the case of trauma, the greater that discomfort and
the need to escape it. Although the addict’s self-loathing is much exacerbated by
the behaviours associ ated with addiction, the self-hatred long predates the
addiction.
While the ASAM cites some of the cerebral circuits implicated in addiction,
what it does not explain is that these brain circuits develop in interaction with the
rearing envi ronment and that under conditions of stress and trauma, key brain
circuits of reward, motivation, emotional self-regulation, impulse control, stress
 response—all impaired in addiction—do not develop optimally. To quote a seminal
article in Pediatrics from the Harvard Center on the Developing Child:

The architecture of the brain is constructed through an ongoing process

that begins before birth, continues into adulthood. . . . The interaction of
genes and experiences literally shapes the circuitry of the developing
brain, and is critically influenced by the mutual responsiveness of adult-
child relation ships [italics added], particularly in the early childhood years.
(Shonkoff et al., 2012, p. 4)

Many studies have shown that trauma and neglect interfere with healthy brain
development and thus create the neurobiological template for addiction. The
hormone pathways of children who have been sexually abused are chronically
altered (De Bellis et al., 1994). Even a relatively “mild” stressor such as maternal
depression—let alone neglect, abandonment or abuse—can disturb an infant’s
physical stress mechanisms (Essex et al., 2002). Add neglect, abandonment or
abuse, and the child will be more reactive to stress throughout life. A study
published in JAMA concluded that “a history of childhood abuse per se is related to
increased neuroendocrine [nervous and hormonal] stress reactivity, which is further
enhanced when additional trauma is experienced in adulthood” (Heim et al., 2002,
p. 117). A brain pre-set to be easily triggered into a stress response is likely to
assign a high value to substances, activities and situations that provide short-term
relief and show less interest in long-term consequences. In contrast, situations or
activities that for the average person are likely to bring satisfaction, such as
xvi Fundamentals of Addiction: A Practical Guide for Counsellors

intimate connections with family, are undervalued, because in the addict’s life, they
have not been rewarding. This shrinking from normal experience is also an
outcome of early trauma and stress, as summarized in a recent psychiatric review
of child development:

Neglect and abuse during early life may cause bonding systems to develop
abnormally and compromise capacity for rewarding interpersonal relation
ships and commitment to societal and cultural values later in life. Other
means of stimulating reward pathways in the brain, such as drugs, sex,
aggression, and intimidating others, could become relatively more attractive
and less constrained by concern about violating trusting relationships. The
ability to modify behaviour based on negative experiences may be
impaired. (Pedersen, 2004, p. 106)

Even when genetics play a role in predisposing someone to an addiction, the

lat est brain development data and, saliently, the findings of the literature on
epigenetics, clearly show that genes are turned on and off by the environment, and
thus are influ enced by experience. For example, children with serotonergic gene
abnormalities that may predispose them to addiction will not express those genes if
they are brought up in a nurturing, supportive family. Reporting on a study
published in the Journal of Consulting and Clinical Psychology, ScienceDaily
(2009) highlights the importance of environment: “A genetic risk factor that
increases the likelihood that youth will engage in substance use can be neutralized
1
by high levels of involved and supportive parenting.”
If addictions are a response to pain and reflect the disordered neurobiology of
childhood stress or trauma, they are also self-medications in the narrow medical
 sense. People with attention-deficit/hyperactivity disorder self-medicate with
stimulants such as cocaine, nicotine or crystal meth; people with post-traumatic
stress disorder with opiates; people with anxiety with benzodiazepines; and people
who are depressed with cocaine and other substances. Of course, the addictive
substances can damage the brain and cause further mental pathology, such as
psychosis and depression. Concurrent dis
orders should not be seen as the exception, but the rule.
Many aspects of addiction theory and practice are covered in this book, and
rightly so. Addiction cannot be understood from an isolated perspective. It is a
complex human condition, a condition rooted in the individual experience of the
sufferer and also in the multi-generational history of his or her family and—not least
—also in the cultural and historical context in which that family has existed. The
shameful statistics of addiction prevalence among First Nations people are not
attributable to any genetic flaw, but to the historical trauma endured by the
Aboriginal populations of North America; the hor
rendous multi-generational legacy of the residential schools; and the ongoing social,
economic and cultural ostracization that continues to be their lot.
We see the same phenomenon with colonized peoples elsewhere. Beyond
margin alized racial or economic groups, many suffer from the anomy and spiritual
emptiness
1 For a refutation of the mistaken assumptions underlying the twin studies that seem to buttress the genetic hypothesis,
see Maté (2008).
xvii Foreword

of a materialistic culture and its constant blandishments to fill our inner void with
external acquisition or attainment, pursuits that themselves can become addictive.
“It is impossible to get enough of something that almost works,” the researcher and
physician Vincent Felitti once aptly remarked.
To its credit, the ASAM definition of addiction recognizes the spiritual dimen sions of
the all-too-human problem of addiction. Spirituality in this context does not
necessarily have a religious meaning, though for some people it may. More broadly,
spirituality refers to people’s innate capacity to connect to their own deeper
conscious ness, to a sense of innate value independent of external factors, to a
confidence that we are more than just our rigidly reactive personality patterns and,
finally, to a belief in a profound unity with all that exists. For addicts, one of the
outcomes of suffering from early adversity is an alienation from these life-affirming
qualities. When we recover, what do we find again but those inner truths? In finding
them, we recover ourselves.
To recover, the addict surely does not need more punishment, more loss,
more defeat. The addict has experienced those in sufficient measure already. On
the contrary, according to the Catholic monk and mystic Thomas Merton, to find
ourselves “we must know what victory is and like it better than defeat.” Victory is
the recognition of our humanness, that we belong, that we are not damaged goods
after all.
Our society is far from understanding that addicts, having suffered since child
hood, need our expertise, our support and, above all, our compassion. In that
sense, addiction professionals need to be more than health care providers—they
need to be social pioneers.

References
 American Society of Addiction Medicine (ASAM). (n.d.). Definition of
addiction. Retrieved from www.asam.org/for-the-public/definition-of-
addiction
De Bellis, M.D., Chrousos, G.P., Dorn, L.D., Burke, L., Helmers, K., Kling,
M.A., . . . Putnam, F.W. (1994). Hypothalamic-pituitary-adrenal axis
dysregulation in sexually abused girls. Journal of Clinical Endocrinology &
Metabolism, 78, 249–255.
Dube, S.R., Felitti, V.J., Dong, M., Chapman, D.P., Giles, W.H. & Anda, R.F.
(2003). Childhood abuse, neglect, and household dysfunction and the risk of
illicit drug use: The adverse childhood experiences study. Pediatrics, 111,
564–572.
Dube, S.R., Miller, J.W., Brown, D.W., Giles, W.H., Felitti, V.J., Dong, M. & Anda,
R.F. (2006). Adverse childhood experiences and the association with ever
using alcohol and initiating alcohol use during adolescence. Journal of
Adolescent Health, 38, 444.e1–e10.
Essex, M.J., Klein, M.H., Cho, E. & Kalin, N.H. (2002). Maternal stress
beginning in infancy may sensitize children to later stress exposure: Effects
on cortisol and behaviour. Biological Psychiatry, 52, 776–784.
xviii Fundamentals of Addiction: A Practical Guide for Counsellors

Gordon, H.W. (2002). Early environmental stress and biological vulnerability to

drug abuse. Psychoneuroendocrinology, 271, 115–126.
Heim, C., Newport, D.J., Wagner, D., Wilcox, M.M., Miller, A.H. & Nemeroff, C.B.
(2002). The role of early adverse experience and adulthood stress in the
prediction of neuroendocrine stress reactivity in women: A multiple regression
analysis. Depression and Anxiety, 15, 117–125.
Maté, G. (2008). In the Realm of Hungry Ghosts: Close Encounters with
Addiction. Toronto: Knopf Canada.
Pedersen, C.A. (2004). Biological aspects of social bonding and the roots of
human violence. Annals of the New York Academy of Sciences, 1036, 106–
127.
Richards, K. (2010). Life. London, United Kingdom: Weidenfeld & Nicolson.
ScienceDaily. (2009, February 16). Genetic risk for substance use can be
neutralized by good parenting [Press release]. Retrieved from
www.sciencedaily.com/ releases/2009/02/090210125437.htm
Shonkoff, J.P., Richter, L., van der Gaag, J. & Bhutta, Z.A. (2012). An integrated
scien tific framework for child survival and early childhood development.
Pediatrics, 126, 460–472.
1

SECTION 1

THE BASICS
 2

Chapter 1

Biopsychosocial Plus: A Practical

Approach to Addiction and
Recovery
Wayne Skinner and Marilyn Herie

This introductory chapter provides an overview of the key concepts and principles
that shape and guide this book on the fundamentals of addiction. It is organized
around sev eral key questions: What is addiction? What can be done to prevent and
treat addictions? How does change happen? And what does recovery mean?
The problem for the practitioner is how to organize the growing torrent of infor
mation and materials that threatens to flood our minds as we work to understand
and help people affected by addiction. The domain of addiction appears to be
expanding, from the well-defined space of substance use problems to a broader
set of addictive behaviours. This expansion raises fears that the concept of
addiction has become so general that it risks becoming meaningless and of little
use as a concept. A truly con temporary approach to addiction must have a realistic
understanding of the impact of addictive behaviours on individuals, families and
communities. From a science-based perspective, sufficient knowledge and skill
exist to be able to understand addictive pro cesses and to constructively address
the problems associated with addictive behaviours. It is both necessary and
possible to build evidence-informed pathways that lead to better prevention,
identification and treatment of addiction problems. If there is a foundational
message guiding this book, it is this: addiction is something we can do something
about. The compilation of expert knowledge this book gives us contributes to a
comprehensive understanding of addiction and the problems related to it. And it
asserts very clearly that there is much we can do to help people affected by
addiction move toward the recovery and well-being they seek.

Understanding Addiction
Our approach to understanding addiction is based on a model that extends beyond
the biopsychosocial (BPS) model originally proposed by Engel (1977) to what we
refer to as a biopsychosocial plus approach. This evolving framework for
understanding addiction builds on the three dimensions proposed by Engel to
include culture and spirituality. We also extend the social dimension to emphasize
socio-structural and macro-societal
4 Fundamentals of Addiction: A Practical Guide for Counsellors

factors, especially those rooted in historical and contemporary socio-economic

inequali ties. These are essential considerations for understanding and addressing
 the social determinants of health.
We believe it is important to explicitly identify these additional aspects. We
agree with Alexander (2008), Maté (2008) and others who argue that we should be
open to considering other factors as well—from economic to anthropological to
psychodevel opmental. Four decades ago, Engel’s (1977) proposal was to move
beyond a narrow, reductionist biomedical approach to health problems by including
psychosocial factors, but that space needs to be widened even further for a fully
evidence-informed, integrated approach to addiction. While there is a growing
acceptance of the mind-body connection and its role in problems such as addiction,
a primarily biopsychological model locates addiction as essentially a medical
condition that requires medical treatment, a problem that is played out in the bodies
and brains of people who have inherited or acquired vul
nerabilities. While this does advance our understanding of addiction beyond the
moral judgments that shaped its social perception for centuries, the expanded
biopsychosocial plus (BPS+) framework offers the comprehensive scope needed
for a more pragmatic, effective approach to preventing and treating the problems of
addiction.
For people involved in the practical work of treating addictive behaviours, the
BPS plus model is offered as a useful conceptual tool. First of all, this model is
compre hensively multi-dimensional—BPS+ seeks to provide a full and rounded
understanding of addictive behaviours and of their prevention and treatment.
Second, the model is integrative: these dimensions do not exist as separate or
disconnected vectors, but as intertwined and interdependent elements. A third
element of the model is that it is pluralistic. BPS+ rests on a radical suspicion of
explanations that reduce the essence of addiction to any one of these domains in
ways that exclude the others. Instead, the model is open to the widest range of
interventive approaches and methods that help clients to reduce the harms
associated with addictive behaviours and to enhance their functioning and well-
being. We expect the world of addiction theory and practice to be a contested
space, where differences in approach are welcomed and critiqued, and required to
prove themselves. We expect proponents in each area to make their strongest,
most compel
ling cases for the merits of their fields of understanding and intervention, pointing
out the limitations and the lacunae in knowledge and methods that apply to their
particular approach. Since we want to ensure that clients have options and
choices, we are bent on keeping open care pathways that include all these
dimensions as clients and communi
ties seek to thrive and flourish beyond the constraints of addiction.
If there is more to human beings than even a multi-dimensional, integrative,
plu ralistic model articulates, BPS+ at least draws us toward an understanding of
the whole person. Having a non-reductive understanding of human beings means
having an active understanding of the person affected by addiction by actively
working to include all five dimensions in the practical work of preventing and
treating addiction.
The BPS+ model draws on the empirical evidence and conceptual models
that inform our understanding of psychoactive substance use disorders, as well as
emerging
Chapter 1 A Practical Approach to Addiction and Recovery
5

knowledge about behavioural addictions that do not involve substance use. These
behav ioural addictions have as strong a biological dimension as those related to
the use of psychoactive drugs, plus profoundly psychological, social, cultural and
 spiritual aspects.

What Is Addiction?
Addiction is the tendency to persist with an appetitive or rewarding behaviour that
pro duces pleasure and sates desire, despite mounting negative consequences that
outweigh these more positive effects. The person feels caught in this appetitive
behaviour, and does not want to or cannot seem to moderate or stop it. Negative
consequences include preoccupation and compulsive engagement with the
behaviour, impairment of behav ioural control, persistence with or relapse to the
behaviour, and craving and irritability in the absence of the behaviour (Maté, 2008;
National Institute on Drug Abuse [NIDA], 2010; Orford, 2000).
Perhaps the most common and archetypical example of a contemporary
addiction is tobacco use: most people who smoke acknowledge that, given a
choice, they wish they had never smoked or, more modestly, could stop. They
certainly would not want their children or other family members to start. Most
people who smoke have made at least one quit attempt over their lifetime but have
been unsuccessful. Indeed, most success
ful ex-smokers had to make repeated attempts at cessation before they achieved a
lasting result (2008 PHS Guideline Update Panel, Liaisons, and Staff, 2008).
Addictions are behaviours—they have to be enacted or performed: drinking alco
hol, inhaling tobacco smoke, injecting heroin, snorting cocaine, pressing the button
on a slot machine, buying a lottery ticket, eating food, having sex, shopping online.
None of these behaviours is inherently addictive, but they all have addictive
potential. They start out as behaviours that a person chooses to engage in, but
become addictive when the person becomes caught up in them in ways that
produce harmful consequences. A characteristic of addiction is the degree to which
the person persists with the behaviour, reverting to it to feel pleasure and to find
relief from pain and distress. In its more advanced forms, the person loses control
over the behaviour. The feeling of loss of control is what people with more severe
addictions commonly report as a defining char acteristic of their problem.
Implicit in this model is the concept of addiction as occurring along a contin
uum. Addiction is not a binary either/or problem that you have or don’t have. We are
all on this continuum in terms of risk and harm. Depending on our situation, which
can change depending on our physical health, emotional stress, social dislocation
or other factors, we become more or less resilient or more or less at risk and
“under the influence” of addiction.
6 Fundamentals of Addiction: A Practical Guide for Counsellors

Addiction as a “Disorder”
For the counsellor in a health care setting, the American Psychiatric Association’s
Diagnostic and Statistical Manual of Mental Disorders (DSM) has governed the way
addic tion has been constructed as “disorder.” The DSM-IV, in effect from 1994 until
the spring of 2013 (including a revision, DSM-IV-TR, in 2000), shaped diagnosis
and the clinical perception of substance use disorders and other mental health
problems. The new version, DSM-5 (APA, 2013), combines what were two levels of
diagnosis—sub stance abuse and substance dependence—into one category—
substance use disorders, or diagnoses that require specification of a particular
substance (e.g., cannabis use disor der). The severity of the disorder is determined
by the number and gravity of symptoms. Using a checklist, the clinician uses the
 number of symptoms to determine whether the client has no disorder, or a mild,
moderate or severe addictive disorder. The term “addiction” was deliberately not
used in DSM-IV, and was instead replaced by “substance abuse” and “substance
dependence.” However with the DSM-5, the term addiction has been reintroduced,
and substance abuse and substance dependence have been removed. The
overarching category becomes “substance-related and addictive disorders,” which
includes behavioural addictions that are not substance-use related.
The diagnosis of “pathological gambling” in the DSM-IV has become
“gambling disorder” in the DSM-5. This allows gambling problems to be ranked
along a continuum of severity, and acknowledges that problem gambling can be
effectively understood in a paradigm of addictive behaviour. In doing so, it escapes
the stigmatizing label that came with the term “pathological gambling.” The DSM-5
also includes “behavioural addictions, not otherwise specified,” a catch-all category
for addictions that do not have a specific DSM diagnostic identity. The DSM panel
did not include disorders such as Internet, sex and shopping addictions because of
a current lack of scientific evidence to support these as clinical disorders.
These changes reflect a more dimensional understanding of addictions as
occur ring on a continuum. They also create a context for framing addiction within a
broader context than substance use alone. By expanding the scope of what is
considered an addictive disorder, there is the potential for more people to be
identified with less severe symptoms, and for them to be helped earlier and with
less intensive interventions than people whose problems have become more
severe and require more involved services and supports.

Addiction as a Dimensional Problem

The move from a categorical to a dimensional understanding of addiction is evident
not just in the DSM-5, but also in other attempts to understand addictive
behaviours. For example, Miller and colleagues (2011) propose that addiction can
be characterized by assessing severity along seven dimensions: use, problems,
physical adaptation, behav-
Chapter 1 A Practical Approach to Addiction and Recovery
7

ioural dependence, medical harm, cognitive impairment and motivation to change.

Each dimension is independent and all are interrelated, occurring along a
continuum. On each dimension, a person can be evaluated on a gradient from low
to high. This approach provides the counsellor with a fairly straightforward heuristic
tool that maps out in a nuanced way the client’s problems and progress toward
meeting his or her goals without the more formal rigours of a DSM-5 diagnosis. The
framework opens up a range of interventive options that can be drawn on to design
treatment approaches that align with the level of care appropriate for each person
in delivering client-centred care.

A Biopsychosocial Plus Model

To work therapeutically to address addictive behaviour, we need more than just
knowl edge about addiction: we need the skillful ability to apply knowledge to
clinical practice in real-life situations.
Here we describe five dimensions that will not only help counsellors
understand the nature of addiction problems, but will also open up essential
 pathways leading to change and recovery.

The Biological Dimension

The 1990s were dubbed the decade of the brain in medicine, ushering in the age of
neu roscience. Advances in medical technology, such as neuroimaging and brain
scanning, have had immense consequences for understanding addiction. In 1997,
Alan Leshner, then head of the U.S. National Institute on Drug Abuse (NIDA),
published a summative article on the neuroscientific view of addiction: “Addiction is
a brain disease, and that matters” (Leshner, 1997, p. 45). Since then, the U.S.
National Institutes of Health and the World Health Organization have pushed to get
addiction seen as both a brain disease and a chronic illness. There are two main
themes in this message: genetic differences explain the variability in people’s
vulnerability to addictive behaviour, and addictive behaviour, particularly the use of
psychoactive substances, changes and disorders the brain in ways that are
demonstrable using neuroscientific technologies.
These technological advances have encouraged the reductionist view that neuro
biological approaches to addiction could win the war on drugs. The neuropathways
of addiction lay the groundwork for pharmacotherapeutic solutions that promise to
eliminate urge, counter and cancel the powerful euphoric effects of psychoactive
substances, resolve withdrawal problems and eliminate the urges that lead to
relapse that is so endemic to addiction. Even if some of these enthusiasms have
not yet been proven, the advances of neuroscience have constructively elevated
addiction from moral failing to valid health problem, not just needing treatment, but
treatable by an emerging pharmacopoeia.
In addiction treatment today, it is vital to be aware of the biomedical nature of
addiction problems and the ways that medicine intervenes, from overdose and
8 Fundamentals of Addiction: A Practical Guide for Counsellors

withdrawal management to medication-assisted treatments to pharmacotherapies

that reduce relapse risk. From the neuroscience perspective, three main factors
contribute to addiction: genetics, environment and human development (NIDA,
2010).
It is important not to reduce the biological dimensions of addiction to
neurobiol ogy alone. Addiction is affected by and affects a person’s biological
functioning in many ways. Basic aspects of healthy functioning, such as diet,
nutrition, sleep and self-care, are often compromised by addictive behaviour.
Understanding the impact of these fac tors and considering them when addressing
addictive behaviour can help people make positive changes and participate
effectively in treatment and recovery. The biological dimension in that fuller sense
is a key pathway, particularly to stabilizing and engaging someone whose life has
been seriously disrupted by a chaotic lifestyle that has com promised physiological
functioning. Addictive behaviours are profoundly biological in nature, and they
require that we have an active and effective understanding of other dimensions,
including the psychological.

The Psychological Dimension

The brain is to neuroscience what the mind is to the psychological dimension,

guiding our understanding of addiction, and the ways that behaviour is shaped and
moulded. Many psychological models, informed by science, govern our
 understanding of addiction, from classical and operant conditioning to social
learning theory and the transtheoretical model (Kouimtsidis, 2010).
Heyman (2009) recently referred to addiction as a “disorder of choice.” His
views run counter to many popular views of addiction, including those held by
people with addictions, who report that they have lost the ability to control their own
behaviour. The element of choice and intention that might have existed early on is
diminished and ulti
mately lost as a severe addiction develops. A behavioural perspective would argue
that even the most mysterious behaviours are governed by laws of reward and
reinforcement. Heyman and others show that when the operants (the positive and
negative reinforce ments) are altered, seemingly intractable addictive behaviour
changes in response (Heyman, 2009; Pickard, 2012). They cite literature showing
that when the setting is changed, as with American GIs in Vietnam, the rates of
addiction normalize. In the extreme environment of a combat zone, soldiers used
powerfully psychoactive substances to cope and self-manage, but when they
repatriated, the rates of addiction reverted to what they would have been if these
soldiers had not been in combat (Robins, 1973).
Other studies have shown that if the rewards are changed, the behaviour is
affected. For example, people addicted to opioids who are paid not to use drugs or
who are enrolled in token economies where they can earn rewards for not using are
able to cut back or stop their use, even when the reward is quite modest. Heyman
(2009) observes that in the modern industrial and post-industrial world, with the
growth of appetitive commodities, people are being exposed to more addictive
oppor
tunities throughout the life cycle. He suggests that from childhood to old age, we tend
Chapter 1 A Practical Approach to Addiction and Recovery
9

to over-consume what we like best as part of our nature. As we live in more affluent
circumstances and technology produces more and more appetitive products for us
to consume, problems that were previously restricted to powerful drugs and a few
other behaviours now can be evoked by an astonishing array of products, from the
Internet to shopping to food. These psychological perspectives heighten our
understanding of how we make choices and how the reward structure and
abundance of modern life affect our appetites, desires, decisions and behaviours.
Just as importantly, the psychological dimension allows us to understand and work
with motivation, perception, expectancy, reward, meaning and maturation in
helping to find solutions to addictive behaviours by developing behavioural
alternatives that are more effective in helping individuals, fami lies and communities
thrive and flourish.

The Social Dimension

Leading thinkers in the biological and psychological sciences point to the decisive
role of environment and how human development and life take place within an all-
pervasive social surround (Leshner, 1997; NIDA, 2010). They point to the active
and co-productive interplay among biological, psychological and social factors in
addiction. While human biology and psychology are malleable, they also have
limits and constraints. The prob
lems of addiction emerge and can be more decisively resolved by the ways in which
we are shaped by social realities, for example, by our socio-economic status, and
depending on our access to housing, proper nutrition and health care.
 A social-structural perspective
Typically the social dimension is considered to be the immediate interpersonal
domain that is most proximal to the person who develops an addictive disorder. We
think of the person’s family and friends, workplace, leisure companions and faith
community. These are all important in terms of how they increase risk or support
resilience. However, we believe we need to take a broader view that includes
macro-social factors. For example, issues related to class, race and gender are of
great consequence in attempting to deal with issues related to addiction. This more
comprehensive socio-structural perspective is essential to understanding the social
underpinnings of addictive behaviour.
Seeing the social dimension as including broader socio-structural factors
leads to a public health approach to social and health problems such as addiction.
The social determinants of health are significantly correlated with addictive
behaviours. In very direct ways, social disadvantage and social factors, such as
access to employment, food and transportation, as well as stress, early life
experiences, education opportunity, social exclusion and unemployment, shape the
health outcomes of addictive behaviour. Not only is addiction in any community
shaped by these factors, but addiction itself is a co-factor in the social determinants
of health in that addictive behaviours compromise personal and community health
even further (Wilkinson & Marmot, 2003).
10 Fundamentals of Addiction: A Practical Guide for Counsellors

Alexander (2008) presents an alarming view of the growth of addiction prob

lems in contemporary society. He observes that, while social determinants
contribute to addiction in predictable ways, more ominous forces cause what he
describes as “the globalization of addiction.” In his view, people and communities
are more or less vulner able to addiction depending on the degree to which they
experience the alienating effects of dislocation.
Starting with psychosociological observations of the effects of colonization on
Aboriginal communities on Canada’s West Coast, Alexander (2008) has developed
a comprehensive and dynamic model to explain some of the profound psychosocial
prob lems of modern life. He posits that mental and community health require
mature adults capable of independent agency and decision making who are at the
same time socially integrated and engaged. Because of the power of free market
society to produce enticing products, our appetites and desires become
commodified, available for purchase in an ever-expanding and deepening web of
products for sale. Addiction is not the problem; rather, it is what people who have
been dislocated resort to as their lives become impov
erished and dis-spirited. Alexander notes how habits grow and become
overwhelming preoccupations requiring people’s involvement at the cost of the
balanced living that creates well-being. What emerges is not a single overwhelming
habit, but a complex of addictive behaviours, all of which result in “overwhelming
involvement . . . that is harmful to the addicted person and to . . . society” (p. 48).
Alexander’s concern is that addiction, understood this way, is not remedied by just
improving the material condi
tions of existence. Indeed, as Heyman (2009) suggests, it is the profusion of
consuming passions that leads to the growth of addictive behaviours in
contemporary consumerist society. Alexander (2008) argues that we instead need
to find other remedies for the dis location that produces the “poverty of the spirit”
from which people take refuge through addiction. Dislocation, classically seen in
marginalization and disadvantage, now is a product of affluence in communities
that are well off but dis-spirited and devoid of deeper purpose.
 It is important not to assign an exclusively negative valence to addictive
behaviour. Addictive behaviours are powerful for people who have given
themselves over to them, which is what the word “addiction” means in the
dictionary or etymological sense: to give yourself over, to award yourself to, to
surrender yourself to the addictive behaviour. In that regard, the challenge in
addressing addiction is not just to stop the behaviour, but to find alternatives that
are meaningful to people, without the harmful consequences that characterize
addictive behavours.
Addictive behaviours occur in the social surround that gives shape and
contour to our lives. This social dimension has a depth and range that encompass
the proximal and local sphere of our immediate interactions and connections with
family, friends, neighbours and others we encounter in our daily lives and the larger
set of societal and socio-structural factors that forms the rules, assumptions,
presumptions and norms, as well as the very conditions we experience in any
society, on the basis of gender, race, class, age, education and countless other
factors that shape our identities.
Chapter 1 A Practical Approach to Addiction and Recovery
11

The Cultural Dimension

“Culture” needs to be allowed to carry the widest connotations possible. It refers to

the essential importance that cultural rediscovery can have for indigenous people,
refugees or members of often-marginalized communities who are able to speak
their own lan guage together, grieving, nurturing and celebrating their identities, the
present and the future. It can refer to young people in a secular materialist culture
who create ceremo nies and rituals that evoke ecstatic experience and communal
celebration. It can refer to people who feel marginalized by sexual orientation and
preference.
Culture is that essential ingredient that is missing when considering people’s
vul nerability to addiction: culture may have been lost or not yet created, causing
someone to suffer, as Alexander (2008) puts it, from dislocation. The more people
find themselves in a cultural surround that respects them, that expects positive
contributions from them (and rewards them for these) and that supports and
protects those in need, the healthier the community and the members who
compose it.
Even approaches that are usually criticized and challenged from the vantage
point of those who emphasize the importance of culture acknowledge the need to
have a culturally informed understanding of people affected by addiction. Both the
DSM-IV and DSM-5 have tools to help the clinician make a cultural formation of the
client’s situation, reflecting a widespread awareness and acceptance of the
importance of understanding the client’s cultural belief system. Addiction as a
concept is subject to interpretation through the lens of the culture—indeed the
many cultures that inform and shape meaning for clients and counsellors alike. The
question is not whether we should examine cultural factors, but how we will do so.
This cultural dimension offers a powerful way of approaching addictive behaviours
and is entwined with other key factors, including spirituality.

The Spiritual Dimension

If you listen closely to your clients who are struggling with addictions, you will hear
about the importance of spirituality in their lives, whether religious or non-religious.
 Finding a personal “cure” for the crisis of meaning is a challenge faced by many
people caught in addictive behaviours. Because this problem has to be resolved
from the inside out, rather than prescriptively, it is important to respectfully keep the
spiritual dimension as wide open as possible. This means keeping it open so that
the therapeutic imagination respects the freedom of each person to find answers to
their own questions in their own way. It involves supporting each client in searching
for, connecting and making contact with the widest and deepest sources of wisdom
and grounding that there are to be found.
We know that spirituality, in any form, can be protective of health and well-
being, and is positively associated with lower rates of addictive behaviour. We also
know that for many people devastated by addiction, spiritual affiliation and practice
open up powerful
12 Fundamentals of Addiction: A Practical Guide for Counsellors

paths for healing, recovery and growth. Many people seek escape and temporary
tran scendence through addictive behaviours, and many people draw on spiritual
resilience and support to bring themselves out of the hopeless places they have
wandered into. The power of mutual aid and peer support lies very much in the
fellowship of others suffer ing in ways that are similar, working for solutions that are
deeply personal and the result of the hard work of disciplined practice. But the
quest for the peace and mindfulness that come with being spiritually centred is a
common denominator in many healing journeys (Humphreys, 2004).
Gabor Maté (2008) provides a carefully constructed narrative of how
addiction can be found in many forms of human behaviour. He found the most
devastating levels of addiction in the lives of women and men living profoundly
marginalized lives in down town Vancouver. At the same time, he makes a much
more comprehensive case for the BPS+ model of addiction, drawing out in detail
the biological, psychological and social factors that co-construct addiction as a
persisting human problem.
Each of the dimensions we highlight in the BPS+ opens up a key vector to an
effec tive understanding of addiction for the practitioner, but even more importantly,
these dimensions represent essential pathways to healthy functioning. Addiction
treatment is the skillful ability to work with people affected by addictive behaviour,
drawing on all of the resources that a comprehensive BPS+ approach offers, as
needed in the stages and phases of the journey toward recovery and well-being.

figure 1-1: Biopsychosocial Plus Model

Bio

Psycho

Social

Cultural

Spiritual
Chapter 1 A Practical Approach to Addiction and Recovery
13
 Addictive Behaviours Can Be Prevented
A BPS+ model sees addiction as existing on a continuum from absent to mild to
moder ate to severe. This approach also sees addiction as a variable: the presence
or absence of addictive behaviours and their degrees of severity will vary over time,
in both directions. In an ideal world, addiction would primarily be addressed
through effective prevention. A growing evidence base now exists from which to
design, deliver and measure preven tion efforts (Canadian Centre on Substance
Abuse [CCSA], 2007a; Health Canada, 2002; Heather & Stockwell, 2004; NIDA,
2003).
Because everyone is at some level of risk for addictive behaviours, universal
prevention strategies are foundational for maintaining and enhancing health and
well being among the entire population. Prevention strategies can also focus on
particular individuals and groups with identified higher risks for addictive
behaviours, such as families with intergenerational histories of addiction, people
who carry identifiable genetic vulnerabilities, and populations with identifiable
deficits in parenting skills, neighbourhood resources and the social determinants of
health. Counselling and edu cational efforts can help particular individuals, families
and groups know their risks and support them in developing and using skills to
avoid problems with substance use and other addictive behaviours.
Using the BPS+ framework, a comprehensive prevention strategy would look
at all five dimensions we describe. Building healthy families and communities
through effective health promotion policies and practices is the most fundamental
step that can be taken to reduce addictive behaviours in a society. Advocates for
each of the five dimen
sions are joined in endorsing that imperative (Alexander, 2008; Heyman, 2009;
Health Canada, 2011; NIDA, 2010). Risk and protective factors for young people
have been identified at the individual, family, peer and school levels (CCSA,
2007b). The evidence suggests that the early years are the most important for
healthy human development (Sinclair, 2007). Intentional social policies that support
children’s development from conception through the early school years enhance
the efforts parents and communities make to optimize their children’s healthy
development. Prevention efforts with families with young children are essential for
developing not just a physically healthy child who grows into healthy adulthood, but
a psychologically resilient child who matures into a socially intelligent and skillfully
competent adult. The factors identified as affecting resilience include genetic
profile, parental control, family cohesion, parental monitor ing, drug availability, peer
drug use, self-esteem, hedonistic attitudes and the balance between risk and
protective factors (Karoly et al., 2005). How children are bought up shapes their
physical and mental well-being, including their vulnerability to or resilience against
addictive behaviours.
Because we know that prevention and health promotion efforts work, we
know that the number of people with addiction problems can be minimized. In that
sense, the high rates of addiction problems in contemporary society reflect the
inadequacy of our prevention efforts (Alexander, 2008; Sinclair, 2007).
14 Fundamentals of Addiction: A Practical Guide for Counsellors

Addictions Can Be Treated with Early Interventions

If prevention is about reducing risk, treatment is about reducing harm. Treatment
begins where prevention fails. The question with addictive behaviour is how soon
 can intervention be effective? The classic disease model asserts that addiction is a
disease characterized by denial, and that people stop only when they “hit
bottom”—when things get so bad that there are serious consequences. A BPS+
perspective argues that you can’t start soon enough, and that even with prevention
efforts in place, some people will have addiction problems. Sufficient evidence now
exists to prove that addictive behaviours and their associated harms can be
identified early, and that evidence-based strategies exist to guide how, when and
where to intervene (CCSA, 2007a; Conrod et al., 2006; Mushquash et al., 2007).
Problems related to addictive behaviours typically manifest themselves as
early as adolescence and in the early adult years, from age 16 to 24, when as
many as three quarters of these young people will have had previous mental health
issues. For them, early intervention for mental health problems could well prevent
addiction problems (Rush et al., 2010).
Effective, timely and urgent action is crucial, and has many advantages: •
The impact and effects of the addictive behaviour, in all BPS+ spheres, will be
less. • The length and intensity of the intervention needed will be less.
• The cost per case will be less, meaning reduced burden for health recovery
services, so that more resources can be directed upstream to invest in health
promotion and illness prevention.
• The technical clinical skills can be learned by a wide set of health and social
service providers.
• The impact on the life of the client will be less disruptive.
• The client is supported to take responsibility for change, including making choices
about goals and levels of support he or she wants to draw on.
• Action to make change can begin immediately.

Since most people have mild to moderate addiction problems, screening

should be an inherent part of health and social service assessments. Eventually,
this would mean that most addiction interventions would be offered outside the
specialized addiction sector, in community and primary care settings, and in other
specialized environments, such as mental health, physical health, criminal justice,
and child and family services.
The evidence suggests that clients with mild to moderate addiction problems
will have good outcomes with brief interventions that empower them to take a
primary role in the change process. Not only can brief treatments be effective, but
also they do not need to be delivered by specialists in the addiction treatment
system. The work of early identification and early intervention is best syndicated
across the full span of health and social services in a community. Another valuable
factor is that clients tend to respond quickly to early intervention (within six or
seven sessions) if they are going to do well, so that those who do not show
improvement early on should be offered more support.
Chapter 1 A Practical Approach to Addiction and Recovery
15

SBIRT: Screening, Brief Intervention and Referral to Treatment

Over the past decade, a number of techniques and tools have been developed and
evalu ated, enabling health care and social service professions to screen, treat and
refer clients for problems related to addictive behaviours. Approaches for early
identification and intervention include the Screening, Brief Intervention and Referral
to Treatment (SBIRT) model developed by the Substance Abuse and Mental
Health Services Administration (SAMHSA). It is “a comprehensive, integrated,
public health approach to the delivery of early intervention for individuals with risky
 alcohol and drug use” (SAMHSA, 2011, p. 2). The model identifies six
characteristics to be applied in all health care and social service settings:
• brief, quick screening and quick, short interventions
• universal screening (as part of regular intake processes)
• focusing on targeted behaviours (one or more specific problematic behaviours) •
providing interventions in non-addiction settings (e.g., public health settings,
schools, doctors’ offices, family agencies)
• having a seamless flow between screening, brief intervention and referral to
special ized addiction settings
• providing research and experiential evidence to support the approach (using
program outcomes to measure success).

Resources to do SBIRT are now widely available, for example, through

SAMHSA and the College of Family Physicians of Canada.
While SAMHSA acknowledges that risky alcohol use has garnered the most
attention in terms of the SBIRT model, enough evolving evidence exists to support
its application to other problem areas. The model now applies to tobacco use, illicit
drug use, depression, anxiety disorders and trauma (SAMHSA, 2011).
The SBIRT model (see Figure 1-2) starts with screening to allow for a quick
cal culation of risk. Risk is divided into low risk (no further intervention), moderate
risk (brief intervention: one to five sessions lasting five to 60 minutes), moderate to
high risk (brief treatment: five to 12 sessions) and severe risk (referral to
specialized service for treatment).
Fundamentals of Addiction: A Practical Guide Risk
16 Low Risk Moderate
for Counsellors Moderate to High Risk

figure 1-2: The SBIRT Model

Screening
Severe Risk, Dependency

No Further Source: SAMHSA (2011). Intervention Treatment

Intervention Brief Referral to Specialty
Brief Treatment

FRAMES: Six Features of Successful Brief Treatment

In their review of the literature, Bien and colleagues (1993) identified six key
features linked to success in brief outpatient treatment. More than 20 years later,
these six com ponents remain salient and robust markers for the brief treatment of
addictions. The
mnemonic FRAMES has become foundational to evidence-based addiction
treatment: • Feedback: giving the client information that is relevant to his or her
 situation, particu larly around the risks and negative consequences of the addictive
behaviour. • Responsibility: change is ultimately up to the client, from decision
making to taking action to maintaining change, with the counsellor and other
resources available to support, advise, guide and coach the client as needed.
• Advice: the counsellor guides the client on how to modify his or her addictive
behav iour, drawing from clinical experience and the evidence base.
• Menu: the counsellor helps the client see that he or she has different options to
choose from to work toward change.
• Empathy: the counsellor listens respectfully, supportively and attentively to the
client’s personal concerns and goals so the client experiences how the
counsellor is compas sionately working in the client’s best interest.
• Self-efficacy: the counsellor works to enhance the client’s belief that he or she can
succeed at making change happen.

The services and supports provided by the health care and social services
systems need to be more collaboratively connected to form a continuum of care if
clients with addiction problems are to be seen as non-stigmatized consumers who
are welcomed and supported in getting the help they need. Practitioners in the
specialized addiction system
Chapter 1 A Practical Approach to Addiction and Recovery
17

need to share their expertise with other health and social service providers who lack
this specialized knowledge. The National Treatment Strategy Working Group
(2008) has produced practical approaches to identifying and treating addiction
problems that can fit integrally in health care and other systems.

Addiction Treatment: Everything “Works,”

Except When It Doesn’t
Again and again, the research literature on mental health and addiction treatment is
proving to be rich in findings that report the null hypothesis: when well-trained thera
pists deliver two or more well-conceived interventions, both interventions produce
better outcomes compared to those for clients who received no treatment at all, but
there is no significant difference between either intervention. In fact, these findings
apply generally to psychotherapy research (Asay & Lambert, 1999; Miller et al.,
2011). Project MATCH (1997) offers a classic illustration: that research project, the
most expensive random ized control trial ever undertaken on addiction treatment,
demonstrated that three very different interventions offered as brief treatments,
plus extended research follow-up, all produced significant and persisting benefits
for the clients receiving treatment, but with no significant differences among them.
For adherents of particular models and approaches, this is disconcerting. But for
clients, it might be encouraging to know that they could benefit from a range of
evidence-based treatments. One factor that makes a difference when trying to
determine best treatment practices is that some treatments have been more
researched than others, and therefore have a stronger evidence base behind them.
For other treatments, the evidence may be mostly practice based, derived from the
knowledge and skills that come with years of direct front-line work and men
tors who share their clinical wisdom and savvy, without being formally researched.
These two perspectives create tensions between researchers and clinicians.
Another dimension that enters the debate of what gets to count as knowledge
comes increasingly from clients and consumers, people whose perspectives are
 often ignored or disqualified, especially if viewed from the stigmatizing perspective
that peo ple with addictions are in denial and cannot be relied on to speak the truth.
However, in ways that are remarkably empowering, courageous and creditable,
clients are insisting that they too have knowledge, which needs a place in the
conversation about best prac tices. Just as heroically and importantly, family
members and concerned others are also realizing that they have a right to bring
their knowledge and wisdom to the discussion of best practices. Marginalized for
years, clients and families are still struggling to claim their full entitlement to be
recognized as knowledge holders and as consumers who have the right to decide
on the services they prefer and how they are provided.
That meaning is always shaped by and filtered through the fabric of culture is
another factor contesting the narrow positivistic view that excludes knowledge that
cannot meet strict methodological tests of truth. The recent document Honouring
Our Strengths,
18 Fundamentals of Addiction: A Practical Guide for Counsellors

developed by Aboriginal leaders and Health Canada (Health Canada et al., 2011),
is an instructive example of a culturally shaped approach to knowledge and
evidence. The debate is and will continue to be about who is let on to the jury that
arbi trates what evidence-based practices should be. This creates dilemmas for
counsellors, researchers, clients, families and funders who have to defend the
rationale for their deci sions. As consumers, we expect the health care domain to be
excellent, and we would be appalled if we or someone we care about were getting
care of one sort when there was stronger evidence for another form of care.
There is much to work out in addiction treatment, from determining whether
there are advantages to residential over outpatient care (and if so, for whom), to the
merits of abstinence-only goals to harm reduction approaches, to whether to include
significant others and family members in the treatment process. This debate needs
to continue. As stronger evidence emerges, it is hoped that consensus will emerge
among the constituents, all of whom have a stake in the process. In the meantime,
addiction counsellors need a set of effective practices to guide them in the daily
they work they do with people affected by addiction, in the reconstructed way we
have described it here— existing on a continuum and extending to a wide range of
addictive behaviours that carry the risk of harm. Our governing observation is that
everything works in addiction treatment, except when it doesn’t. Even doing
nothing “works.” A certain percentage of people who have identifiable addiction
problems, including very severe ones, improve without seeking treatment, as do
people who are on wait-lists for treatment (Granfield & Cloud, 1999; Miller and
Carroll, 2006).
While we don’t recommend doing nothing, when evaluating addiction
treatments we need to determine whether the treatments are better than what
happens when people take action on their own or are left on a wait-list. Evidence
suggests that people who complete treatment do better, in general, than people
who do not, and that the engage
ment skills of the counsellor are important in retaining clients in treatment (Miller et
al., 2011). We also have evidence that confrontation produces worse outcomes in
treatment than does motivational communication (Miller & Rollnick, 2013). There is
also evidence that some medications work in some situations and have therapeutic
advantages over psychosocial therapies alone. This is consistent with our BPS+
model, which indicates that we can be most helpful by exploring and identifying
pathways in all five dimensions relevant to clients’ present status and treatment
goals.
 We can also advise our clients based on our understanding of the evidence.
For example, a doctor wanting to prescribe a drug to help a person with withdrawal
symp toms would likely choose a drug that has the highest efficacy in addressing
the person’s symptoms. But the drug will not be effective in all cases, for one
reason or another. What will the doctor do next? One option is to do nothing,
because there is no other drug with comparable efficacy. Or the doctor could
consider a second drug, with lower overall effi cacy, but which does work with a
smaller portion of the population. Ideally, the doctor will discuss with the person the
pros and cons of each choice, so the two can arrive at a mutual decision.
Chapter 1 A Practical Approach to Addiction and Recovery
19

In another situation, a counsellor offers a client cognitive-behavioural therapy

(CBT) to treat severe alcohol use disorder. Although the evidence suggests that
CBT is unsurpassed as the treatment of choice, the client has not responded well,
and now is missing sessions. What does the counsellor do? One possibility is to
prevail upon the client to keep going, knowing that if the client quits, the counsellor
has at least offered the best intervention available. Or the counsellor could meet
with the client and identify options to enable the client to make a choice. The
counsellor could also encourage the client to visit other settings that offer different
forms of care and check out mutual aid options. Sometimes our own biases and
opinions, however well informed they may be, are the barrier that keeps a client
from being aware of options in all of the BPS+ pathways to change and recovery. If
our orientation were truly client centred and in the service of the client making
informed choices, no doubt the respect and safety we offer would increase the
likelihood of client engagement.

The How of Helping: Three Predictors of Success in Therapy

Meta-analyses and reviews by Lambert and his colleagues (e.g., Asay & Lambert,
1999) over several decades point to three ways in which counsellors influence the
outcomes in therapy:
• the helping relationship
• the methods and techniques we use
• the hope and positive expectancy we support in the client.

Asay and Lambert (1999) also remind us that a fourth variable belongs totally
to the client: the personal strengths and social supports they have to draw on.

The helping relationship

Of the three ingredients with which we work, it turns out that the helping relationship
is the most powerful variable.
Clients of counsellors who are more empathic tend to have better treatment
out comes than those whose counsellors show less empathy. This suggests that
the how of helping is at least as important in determining outcome as what method
or model of treatment is used. In fact, Miller & Rollnick (2013) maintain that the
ability of the coun sellor to establish and maintain an empathic relationship is the
best predictor of success in therapy. This extends beyond addiction to
psychotherapy in general (Asay & Lambert, 1999; Miller et al., 2011).
Empathy is not just a state of mind, but a demonstrable and measurable skill that is
integral to the work of therapy. Rogers (1951) recognized empathy as the heart of
client centred therapy. Along with highlighting genuineness and unconditional
 positive regard, Rogers felt that empathy promoted change and growth in clients.
As an evidence-based practice in its own right, empathy has a place in any method
of therapy, and is used in varying degrees in motivational enhancement therapy,
CBT and 12-step facilitation.
20 Fundamentals of Addiction: A Practical Guide for Counsellors

The corollary to empathy is confrontation. Confrontation is a win-lose game

you play with a client. If you convert the client to your position, you win. If the client
opposes you and refuses to convert to the position you rightly hold, you lose. You
can invoke stereotypical clinical language—the client is in denial or hasn’t hit
bottom yet. Sometimes you may win, and you get the client to convert, but this is
not likely. It is easier on you and your client to work from a client-centred
perspective, but it is skillful work, improving with practice, client feedback and
supervision by peers and mentors.

Treatment methods and techniques

Even when one treatment is measurably better than another, it should not
necessarily be the only option, just the one to start with. It is likely that the better
intervention works for only a proportion of the clients who receive it, so that an
intervention with a less effective overall success rate might be better for another
segment of the client population. In that way, the better intervention appears to
work with more people more of the time, but the worse intervention, while working
for fewer people, does work some of the time. Efforts to give clinicians decision
rules about best practices in addiction treatment still have a long way to go. That
said, it is essential for optimal client care that counsellors and their agencies know
what are the better and worse clinical practices in treating addiction.

Hope and positive expectancy

Expectancy—sometimes called the placebo effect or the ability to kindle and
sustain the client’s hope for a good outcome—is nurtured through therapist skill
rather than a par ticular “method.” It involves the willingness to work with the client
and demonstrating an active and compassionate interest in the client’s situation as
he or she sees it, reflect ing your sense of respect for the client and your
commitment to putting your time into working together.
Client centred skills allow the counsellor to engage and work with the client
on goals that are important to the client in ways that are negotiated between the
client and counsellor. And the evidence, supported by what clients and counsellors
alike have reported again and again, proves that the how of counselling is at the
heart of therapy.
Figure 1-3 highlights the four factors in counselling that influence the outcome
of therapy, as identified by Asay and Lambert (1999).
Chapter 1 A Practical Approach to Addiction and Recovery
21 figure 1-3: Therapeutic Factors

Related to Improvement

30%
 Therapeutic
Relationship 40%
Extra-Therapeutic
Factors

15%
Expectancy
(placebo
effects) 15%
Techniques

Source: Asay & Lambert (1999).

Treating Addictive Behaviours: Severity

Predicts Complexity
Most of the population is at the low-risk or low-harm end of the addiction continuum.
While only a minority will develop more severe addiction problems, they will usually
require more intensive treatment and support. The likelihood of complexity grows
pro portionally with severity. People who meet criteria for a serious addictive
behaviour have more symptoms or negative consequences, and more pronounced
symptoms or nega tive consequences from their use. Their problems will exist on
some level in each of the BPS+ dimensions, perhaps particularly significant in
some, perhaps less so in others. They are also more likely to have physical and
mental health problems. For example, the risk of certain cancers rises in direct
proportion to the amount of alcohol use. To have an addictive disorder is to have a
significantly elevated risk of having mental health prob lems, and that risk increases
with the severity of the addiction (Health Canada, 2002; Skinner, 2005). This is
another reason why a BPS+ approach is valuable: it helps identify the full range of
issues that need to be understood to make an effective plan based on an accurate
understanding of the client’s needs, strengths and goals.
One way of representing the multi-dimensional aspect of addiction is by
mapping out the problems areas, along with the client’s readiness for change and
the availability of social support, as in Figure 1-4.
22 Fundamentals of Addiction: A Practical Guide for Counsellors

figure 1-4: Mapping Out the Multidimensional Aspects of Addiction

Addictive
Readiness for change behaviours m

Mental health problems

v

itted ed ild
m
s
moderat severe
e
lent a

wea any
m oc a

op

k m
ib
po

Social support stron

g s
ome Other
ew problems
f
 This mapping can be done with the client, as well as collaboratively with a
multidisciplinary team. Tools like this allow tracking over time, as well as helping
with the initial assessment, especially with clients with severe and complex
problems, to help you find an area on which to focus your efforts. Be aware of your
scope of practice—the orbit of things you can and cannot do. It is unrealistic for a
single person to be able to address all of the client’s problem areas and needs. The
more severe and complex the situation, the more important it is not to be working
alone. Ideally, the client and you have access to experts who can address both the
client’s immediate and long-term goals, and can tackle a shared plan together, one
increment at a time.

Helping Change Happen: Building the

Client’s Recovery Capital
As many change narratives attest, most people with addiction problems—even
some with severe addictions and those who do not participate in formal treatment
—do solve or resolve their addiction problems.
A substantial literature on “natural recovery” or “recovery without treatment”
now supports this scientifically, uncovering factors that play key roles in helping
people change addictive behaviours.
While this change is not at all guaranteed, it occurs in significant enough num
bers that clients themselves take note and are given the courage to take healthy
risks to get there.
Chapter 1 A Practical Approach to Addiction and Recovery
23

The reasons that people decide to change are diverse: some people’s
addictive behaviour is damaging their physical health, so that the behaviour is no
longer the source of pleasure and reward it had been; for instance, they may have
contracted HIV or hepa titis C. Other people may decide to change for
psychological reasons because they don’t like or can no longer recognize the
person they have become. Sometimes the decision to change can be motivated by
an embarrassing or worrisome social consequence of their addiction, such as
being arrested, or humiliating public behaviour, such as becoming uninhibited and
sexually compromised while intoxicated, or out of hand at a party. For others, the
threat of losing a job or the breakup of a relationship is what makes them decide to
change an addictive behaviour. Still others change with the desire to get in touch
with their cultural roots and be guided by cultural values. And finally, feeling
spiritually empty and bankrupt may be what propels someone to seek a stronger,
more meaning
ful life. The birth of a child, the death of a parent, or another dramatic life event,
such as surviving a life-threatening event, or getting a serious diagnosis, or seeing
what has happened to someone else you care about or know—these are all
examples people give as the precipitating factors for deciding to change an
addictive behaviour without treatment (Cloud & Granfield, 2008; Granfield & Cloud,
1999; Klingemann et al., 2009).
People with addictive behaviours who can access social support have much
bet ter chances of a sustained recovery. Having problems that lead to low self-worth
and an inclination to isolation or problematic interpersonal behaviour are
precursors to addiction behaviours. The loss of social relationships and social
standing that are often a consequence of addictive behaviour can contribute to the
radical demoralization that comes with a life derailed by addictive behaviour.
 In helping people with addiction, the goal is not just to get them to stop the
addic tive behaviour, but to develop alternatives that adequately meet their needs,
without imposing the severe negative consequences that can come with addiction.
Treatment, especially brief treatment, can only help the person prepare for or start
that process of finding more positive alternatives to their addiction. It usually takes
time for clients to feel that they have moved from the active state of addiction into
the process of, or journey into, recovery.
Drawing on the theoretical work of French sociologist Pierre Bourdieu
(Bourdieu & Wacquant, 1992) and on their own research on recovery without
treatment, White and Cloud (2008) use the concept of “recovery capital,”
introduced by Granfield and Cloud (1999), which describes “the breadth and depth
of internal and external resources that can be drawn upon to initiate and sustain
recovery” from addictive behaviours (Granfield & Cloud, 1999, p. 1). Recovery
capital reflects a paradigm shift in addiction treatment from a focus on problems
and illness to one directed toward solutions and recovery. Cloud and Granfield
(2008) define capital as “a body of resources that can be accumu lated or
exhausted” (p. 1972).
Cloud and Granfield (2008) divide recovery capital into four components: •
Personal recovery capital: either physical (e.g., safe shelter, physical health,
clothing, food, transportation) or human recovery capital (e.g., values, education,
knowledge,
24 Fundamentals of Addiction: A Practical Guide for Counsellors

skills, credentials, problem-solving abilities, interpersonal skills, self-awareness,

self esteem, self-efficacy, sense of purpose and meaning)
• Family and social recovery capital: close relationships with family and kin, and
other connections that support recovery; non-addictive social networks, lifestyles
and activities; and a positive sense of social inclusion and belonging in leisure,
work, faith community or other value-based groups
• Community recovery capital: resources, policies and expressed attitudes that
promote recovery, provide visible role models, provide mutual aid supports, offer
access to treat ment and continuing care resources, and actively support
community reintegration
• Cultural capital: culturally based resources and connections that resonate with
the person’s positive sense of identity and belonging.

What is significant from a BPS+ perspective is the robust dimensionality this

concept brings to the task of resolving the problems of addictive behaviours.
Addiction solutions come not just from stopping the problem behaviours, but from
cultivating healthy alternatives. The following recommendations have emerged
from taking a recov
ery capital approach to addiction treatment (White & Cloud, 2008):
• Screen and offer brief interventions before clients use up their recovery capital. •
Reach out to connect with people who are marginalized and disadvantaged and
have low recovery capital.
• Take a strengths-based approach to ongoing assessment of social
capital. • Determine levels of care on the basis of recovery capital.
• Mobilize resources in as many domains of recovery capital as possible to support
recovery and well-being.
• Make changes in recovery capital a measure of how effective your efforts to help
cli ents change are.
 Conclusion

There are more things in heaven and earth, Horatio,

Than are dreamt of in your philosophy.

—William Shakespeare

Addiction treatment is ultimately about finding solutions to the problems that come
with addictive behaviour. It is a very practical project that requires knowledge and
val ues, and respect and compassion for each client. Most of all, it is skillful work. At
its core is our ability to work empathically and respectfully with individuals, families
and communities affected by addiction, often in extremely challenging
circumstances. The BPS+ model allows us to construct a dynamic and evolving
engagement with clients in the context of addiction and recovery. The biological,
psychological, social, cultural and
Chapter 1 A Practical Approach to Addiction and Recovery
25

spiritual dimensions all contribute to a fuller understanding of clients’ journeys into

addictive behaviour, and each dimension opens up a care pathway that can be
accessed at appropriate points in the phases and stages involved in that second
journey toward recovery. The BPS+ model invites us to look beyond our particular
approaches and scope of practice to the wider landscape of options that give
clients the choices and resources they need to thrive in their communities. In that
sense, it is a model that opens coun
sellors—that diverse, multidisciplinary group committed to finding the best solutions
to the clients in their care—to supporting recovery in ways that are more fulsome
and comprehensive, as well as practical and effective, than can be dreamt of—or
accom plished—by any one approach alone.

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Chapter 2

A Client Perspective
 Cheryl Peever

For my money, memoirs written by addicts recounting their use are usually not what
I would consider reliable accounts of that period in their lives. If anyone implies
they can recall with perfect clarity the places, people, amounts and chronology of
events surround ing their use, it’s usually fiction. What I do trust are stories of
treatment and recovery. People can recall with astounding detail the people they
met, a look, a phrase or a gesture during the early phases of recovery. Your first
experience with treatment professionals is an incredibly powerful moment. Your
senses are heightened, your fear is acute and you are considering making the
most profound change of your life. From the first moment you pick up the phone,
walk into a meeting or attend an assessment, the circumstances of that moment
and the days and weeks that follow become embedded in your memory. Even
people who have relapsed many times and experienced multiple encounters with
addiction professionals can relate important moments of every treatment
experience.
I did not have good experiences with addiction facilities when I was looking
for help, although in fairness to those I came into contact with, I would not have
been considered a platinum client. The symptoms of my illness and the
accompanying agita tion, anxiety, depression and anger made it difficult for me to
advocate appropriately for myself or ask the right questions. I found the system
confusing and frustrating, and it seemed like there were more barriers than access
points. As a professional, many years later, I have been critical of the way clients
are often treated within the addiction and mental health systems and between
those systems, although I admit great improve ments have been made over the last
20 years. It would be wrong to only talk about the problems. In my career as a
social worker, I have encountered incredibly skilled and innovative clinicians who
are trying to do their best in spite of the challenges presented to them by clients
with increasingly complex problems, higher demands for productivity and an
underfunded system.
A chapter about consumer perspectives should not reflect only one voice or
one time period. I decided that I needed to include the voices of others who had
experience with substance use treatment. I began to ask everyone I knew who had
been to treatment if they would speak to me about their experiences. They eagerly
agreed. I also mentioned it to other professionals and asked if they had any clients
who would be willing to talk to me. They did. At a talk I gave to an audience of both
professionals and clients, I put it out there almost as an afterthought; yet I had a
lineup of people wanting to be interviewed.
30 Fundamentals of Addiction: A Practical Guide for Counsellors

Initially, I thought I would ask a couple of people some pointed questions about their
experiences with treatment. Instead I heard a chorus of about 40 people graciously
and thoughtfully telling their stories of treatment, recovery and relapse, and offering
sugges tions for current and future professionals in the field.
Some people agreed to talk to me because they had negative experiences
and wanted to suggest how clinicians and systems could do better. People who
had positive experiences were equally as passionate about wanting to be heard;
they wanted to talk about what worked and why, and to convey the importance
their counsellors played in changing their lives. This was not a representative
 sample of all addicts by any means, but it was a decent cross-section of the
population—people varied in age, gender, ethnic
ity and sexual orientation. Some people who spoke to me were using again; others
were in early recovery; and some had been clean for many years. Several people
had chosen to work in the addiction field because of their journey; others were in
school or worked in other fields, and some were unemployed. People were
surprisingly compassionate toward those who go into the helping profession and
work with addicts, and they were incredibly savvy about the internal pressures
faced by those who work within the system. Nevertheless, we think the system
could work better; clinicians could be trained better, supervised better; and society
could do a better job of understanding addiction and what addicts go through.
Throughout this chapter, I use the terms “addict” and “addiction” because
those are the terms I use for myself. If this were an academic article, I would
probably use terms like “people with substance use issues,” or I would distinguish
between people who are “substance abusers” and those who are “substance
dependent.” But this is a personal piece that conveys personal stories, so I choose
to refer to myself and my com
rades as addicts. Since alcohol is a drug, I include people who used alcohol as well
as those who used chemical or herbal substances. I sometimes refer to “drugs and
alcohol,” even though alcohol is also a drug. Instead of distinguishing the drug
addicts from the alcoholics and using another term for people who are cross-
addicted, I use the word “addict” as an umbrella term, with apologies to those who
may feel squeamish about it. Many of the people I talked to have a concurrent
mental health issue. People don’t refer to themselves as concurrent disorder
clients, nor do they separate their mental health issues from their addiction issues.
While clinicians may think of concurrent disorders as two disorders, those of us
with personal experience generally think of it as one issue that affects our total
experience. I don’t distinguish between the groups.

No one is a textbook case.

The difficulty with papers, studies and books on addiction is that they have to distill
addicts into traits, generalities and common denominators. Trying to place those
templates onto the person in front of you misses the uniqueness and diversity of
who they are, their experience and what they may be trying to tell you. By the
nature of the lifestyle they have been living, and as a survival technique, most
addicts are highly
Chapter 2 A Client Perspective
31

skilled at reading people. Some of us are used to walking into situations where we
must complete a threat assessment in about 30 seconds, and we need to be able to
spot the scam, the rip-off and the empty promises right away. So, we can spot
phoni ness and false bravado a mile away, and can detect weariness, but
distinguish it from impatience, boredom or dismissiveness.
The client studies the clinician and tries to figure him or her out in much the
same way the clinician studies the client—by looking at body language, tone,
speech content, eye contact and so on. Clinicians often unknowingly telegraph
their thoughts and attitudes during an encounter in subtle ways (Maté, 2008). A
client can tell when someone is talking to them as a genuine human being and
listening with compassion and empathy to what they are trying to say. A client can
also tell when someone is mak
ing quick judgments or assumptions and slotting them into a category. A clinician
 can ruin an encounter in only a few seconds, so that initial engage ment with a
client is incredibly important. Even if a client decides not to continue on into a
program, that first experience with you can determine his or her feelings about treat
ment as a realistic possibility some time in the future. If clients know they will be
treated with compassion and respect, they will feel comfortable about coming back.
People who were initially unsure about entering treatment said they engaged in a
program based on the first clinician they met. Overwhelmingly, what hooked people
was being treated with dignity and feeling like that counsellor or that program could
help.
At a recent talk I gave to professionals in a psychiatric program, I put this
question to the audience: “Who would like to see clients treated with more
respect?” Almost every hand in the room went up. When I asked “Who feels like
they treat their clients with respect?” again, almost every hand went up. And
therein lies the crux. Many clinicians think their interactions with clients are
respectful, while others are consistently witnessing disrespectful encounters. If
other clinicians can see it, you can bet your client can as well.
So how can you be sure you are treating clients respectfully? It’s pretty
simple. If you are talking to your client in the same way you would speak to your
boss, a police man, your bank manager or your doctor, you are probably being
respectful. If you are talking to your client like a “street person,” a “sick” person or
as if you don’t care how they interpret what you are saying, then you are being
disrespectful. If when clients are not around you refer to them using terms like
“junkie,” “crackhead” or “drunk,” chances are pretty good you will come across as
disrespectful to your client. As Gabor Maté (2008) put it, “We see their reactions
but don’t realize that we ourselves may be creating what they are reacting to—not
so much by what we say but by who we are being in the process” (p. 384).

I’m an addict. I’m not stupid.

Many folks I talked with expressed frustration that their intellect seemed to be put
into question because of their substance use or substance of choice. Crack users
and meth users in particular felt like they were treated as uneducated or just plain
stupid.
32 Fundamentals of Addiction: A Practical Guide for Counsellors

Counsellors tended to convey this message by speaking slowly and emphasizing

cer tain words with an infantilizing tone or repeating phrases and questions for
emphasis. People with alcohol issues were sometimes treated to prepackaged
slogans such as “just put a plug in the jug” (as if that hadn’t already been tried). As
a former cocaine user, I felt like I was treated as if I had just done a little too much
partying until I mentioned dealing and intravenous use; then I could see in the
clinician’s face that my intelligence quotient plummeted and she was dropping me
down a few notches on the seediness scale as well.
Having a substance use problem says nothing about your intelligence. It says
nothing about who you are, your moral character, your family, your personality, your
potential or your future. When I was at my worst, no one would have ever predicted
I would someday be clean and sober with two degrees and a fulfilling career.
Perhaps that’s because societal stereotypes and media portrayals involving addicts
can sometimes influence clinicians to set their expectations lower than they should.
Additionally, some clinicians who are used to seeing people who are acutely ill on a
daily basis can easily forget that those of us doing well in recovery are not an
anomaly or the exception to the rule, but what professionals should be consistently
 striving for.
Some stereotypes are so common they influence our behaviour without our
conscious awareness. We as a society, and sometimes health care professionals,
tend to marginalize users or take a paternalistic tone based on some of those
stereotypes. It may seem justified to treat addicts as people who need to be told
what to do rather than as thinking, complex people who need help putting the
pieces back together.
While some clients may not be well educated, others are, and many are quite intel
ligent regardless of how far they went in the education system. A good rule of
thumb is to treat clients on the same level they think they are at, not the level you
assume they are at. As one woman told me, “If I don’t understand what someone is
saying I will tell them; they shouldn’t assume I don’t know anything right from the
start.” Many counsellors have difficulty reconciling the discrepancy between a
person who has the capacity to make good decisions for himself or herself yet has
made poor decisions, at least by society’s standards.
Using drugs, using certain drugs, using some drugs in certain ways,
overusing alcohol and becoming dependent on substances are all usually seen as
“stupid things to do.” But addiction has nothing to do with smart or dumb. Smart
and not so smart people can succumb to addiction, and all people make poor
decisions at some point in their lives.
Addiction, when you are in the throes of it, doesn’t feel like a decision at all; it
feels like a necessity. It’s a compulsion, a drive, an obsessive desire to acquire and
use to obliterate unwanted feelings, destroy troublesome thoughts and cope with
the pain of daily living. Addiction runs the control panel in your head and blessedly
makes the small things seem meaningless and the important things trivial. But
having your life run out of control and “needing” treatment doesn’t mean you are
ready for treatment, want treatment or can stick with it. Only a client can make that
decision (unless, of course, the criteria are met for an involuntary assessment). Not
the family, not the friends, not the employer. The drive overruns rationality
sometimes (well, often), but that doesn’t
Chapter 2 A Client Perspective
33

mean the person can’t understand what is being presented to him or her, or what
the options and consequences are. The counsellor does not own the destruction
people do to their lives. The counsellor can’t steal other people’s lessons or take
over their journey. And clients will never follow your timetable. Treat people as if
you trust they can make a rational decision and chances are they will—eventually.

Being dependent on substances is scary. The idea of living

without those substances is scarier.

By the time most people recognize they have a problem and need help, they don’t
remember their life before substances came into the picture. Those who do
remember it may recall things like trauma, abuse, insecurity, social inadequacy,
dysfunctional rela tionships, loneliness, self-destructive thoughts or mental health
issues. The thought of dealing with those issues clean and sober seems
impossible.
People build their lives around their use. The people, places and activities
that make up their existence revolve around the substance of choice. Revamping
and rebuild ing a new life, when this may be all you’ve known, is like being asked to
live in a foreign country. You don’t know the language, the customs or the
behavioural norms, and there is no map. You don’t know how to go about normal
 daily activities because your former activities revolved around acquiring, using and
recovering from your habits. When I first had a little clean time I asked another
woman in recovery what she did with her day. She suggested going to the beach.
What a revelation! I had forgotten there was a beach and that people sometimes
just relax and enjoy things like water, sun and fresh air.
The idea of interacting with “straight people” on a regular basis is another
source of stress. When you have a community of substance users, you have a
culture, a lingo and a shared frame of reference. Learning how to make small talk
and converse with people in situations that don’t involve substances can feel
extremely awkward. Feeling like you don’t belong or don’t know how to cope in the
“straight world” can drive you back to what you know, even though it may be
harmful.
It is not just the particular drug or beverage or what it can do for you that is
addictive. Everyone develops little rituals that accompany their substance use.
Those little rituals become a source of immense pleasure and comfort. To live
without drugs or alcohol means living without the comfort of those rituals. Of
course, new rituals can be developed, but that is hard to imagine when you are
thinking about living your life without your substance of choice.
Clinicians may call the client “resistant” or “ambivalent.” The correct term is
“scared to death.” Knowing you may have to abandon everything you know and get
through the day without chemical assistance invokes terror in your soul. Although
life may have been hard, nasty, dangerous and unhealthy, the fear can make you
want to stick with the devil you know. Many people I spoke with said they wanted a
“normal” life, but most admitted that at the time, they did not know what “normal”
meant or what it would look like. One woman spoke of “wanting it but not wanting
it,” and wondering what it
34 Fundamentals of Addiction: A Practical Guide for Counsellors

would mean to “become one of the pack.” Recognizing and acknowledging that fear
and what a multi-faceted, life-changing moment the client is facing is one of the
best ways a clinician can help a client with choices and further the therapeutic
relationship.

Getting help is step one of a thousand steps you have to take.

Recovery is more than learning to stop certain behaviours or learning to take

medication regularly. People must transform many aspects of their lives and that
may include where they live, who their support system is, their habits, activities and
thinking patterns. No one developed an addiction quickly, so recovery takes time,
lots of time, and can’t be accomplished in 21 or 28 days. Treatment must be
continuous, not fragmented, and must support people through the changes they
are going to experience and see them through the inevitable setbacks. Learning to
live and have a life without substances is a huge undertaking; yet programs don’t
always consider this when deciding what, or if, aftercare will be provided.
There is a huge demand for addiction treatment, yet few new programs. That
places a huge burden on the supply side of the equation. Groups get bigger and
more economical. Budget cuts require staff to do more with less. There is a push to
get people through a program, but not necessarily to get them better. There isn’t
always staff to help with things like case management, finding appropriate housing
and developing support systems and good coping skills. People risk relapse if they
end treatment without any structure or systems in place to help them cope with the
realities of their new lives.
 Did you know what treatment was the first time you went?

A categorical “no.” Treatment is a mystery to those who need it. If you pay attention
to celebrity news, treatment seems like a resort in a remote setting with gourmet
food, tennis courts, individual therapy and yoga classes. Generally speaking, that’s
not what it is unless you have lots of money. Many assume treatment is where you
find a cure, and learn to become a different person. Again, that’s not it. People I
talked to were under the impression that treatment was going to “fix them.” Some
were looking for their problems to disappear; others wanted to understand why
they were using, thinking that would solve the problem; and some simply wanted
the desire for drugs and alcohol to be taken away. These misconceptions about
what treatment will do for you are a recipe for disaster. Unless you truly understand
what treatment is about and what you are sup posed to get out of it, you are likely to
be disappointed with the experience.
There are many kinds of programs, and there are many kinds of addicts and dif
ferent ways to reach them. Some people require a structured program; others will
cut and run as soon as a heavily structured rule-based program is imposed on
them. Some addicts appreciate a standardized program, while others will label it
“cookie cutter” and look for something more suited to their particular needs. Some
find comfort in God, while others reject any form of religion or spirituality that is
introduced. Some addicts
Chapter 2 A Client Perspective
35

respond positively to confrontation, and others would be traumatized by this

approach. That isn’t always made clear when a person walks into a facility, and he
or she may not know what the best approach would be for them. They may not
understand that finding a program that “fits” is an important component of recovery.
People need to know what is being offered and what other options are out
there. If you want to cut down on your drinking or drug use, an abstinence-based
program is not a good fit. If you are only interested in abstinence, and only want to
be around others who are trying to stay abstinent, then a harm reduction program
is going to be a source of irritation and cause resentment toward other clients. If
you are looking for individual psychotherapy, a group-based program will leave you
feeling like you are missing out on something. Many people who spoke with me felt
they did not know what they were sup
posed to achieve in certain groups or programs. Finishing a group and being told
you have “graduated” is nice, but it left many folks wondering what they were
supposed to learn from it and how it was going to help them with recovery. These
things should be discussed at the beginning and at the end of every group, so
people know what it is they are supposed to take away and how they are to apply
it.
Being in a program that is unclear or not suited to what you need can result in
early attrition, early discharge, relapse and generally feeling like a failure. Many
people don’t know what they need because they have never done it before and
may not know what suits them until it is not working. It is helpful to explain to
someone who is not doing well that they may need a different type of program,
rather than have them feel like a hopeless case. Turn it from “you aren’t suited to
our program” to “your needs are legitimate but we are having trouble meeting them
in this kind of program.” It would be helpful for clinicians to know where people can
go to get a different type of program than what they offer if it doesn’t seem to be a
good match.
Remember that relapse is part of recovery. In fact, I’ve never heard of
recovery happening without relapse. It sometimes takes many, many tries, but
 quite often a cli ent who is trying recovery for the umpteenth time is labelled a
“frequent flyer” and may experience a half-hearted effort by the staff. Yet think of
how difficult that must be for that client. To keep relapsing is frustrating, confusing
and frightening. It leaves people feeling like “it can’t be done,” or that they “don’t
have what it takes.” Imagine the courage it takes to go back into treatment and face
the same people, to hold your head up and say you are willing to try again.
Relapse, to people who don’t understand it, is sometimes treated as if it is the
end of the road rather than an indication that there is simply more work to do
around managing the illness. Some programs “call people out” after a relapse and
use punishment and humiliation as a technique. Making people feel worse about
themselves than they already do is not therapeutic; it’s cruel and unjustified
(Kaplan & Broekaert, 2003).
Other chronic illnesses, such as diabetes, multiple sclerosis or rheumatoid arthri tis,
can also produce symptom relapse. Sometimes it occurs for no other reason than it
is a remitting illness; other times the patient may have contributed to it through poor
diet, medication mismanagement or too much stress. I can’t imagine a medical
professional
36 Fundamentals of Addiction: A Practical Guide for Counsellors

handling this by any other means than compassion, education and getting the
person back on track. Your doctor usually doesn’t fire you for not following orders
or making mistakes on the way to learning to manage an illness.
Yet learning to manage substance dependence is often not given the same
leeway. An inexperienced clinician may take it personally and question whether
they can con tinue working with the person because they feel let down or betrayed.
Program leaders may view the person as “not ready” or as “flouting the rules.”
Things like motivation, commitment and competence are put into question.
Clinicians often feel they should decide what they are going to do with the client,
rather than asking the client what they want to do about the program. Professionals
have a lot of power to shape a person’s recovery journey. In some cases, that
power is used to further the staff agenda, and the client is left out of the equation.

What does a great counsellor look like?

People who felt they had a great counsellor could not find enough words to express
their gratitude toward that person who helped them through the most difficult period
of their lives. They were likely to offer the bulk of the credit for their early recovery
to their counsellor, rather than acknowledge any of the heavy lifting they themselves
may have done. When asked what makes a great counsellor, everyone used the
same adjectives.
The first was non-judgmental. Clients who felt like they were not being
judged, sized up or critiqued were able to openly and comfortably discuss the full
range of their issues, experiences and feelings. This was the most significant
precursor to developing trust and respect in the therapeutic relationship. No one I
spoke to mentioned respecting a counsellor based on credentials or years of
experience. What inspired respect was a counsellor’s ability to be non-judgmental.
People who respected their counsellor listened to what they had to say and the
suggestions they would offer, and remembered things they had said. Some quoted
a particular line or phrase their counsellor had used that had an impact on their
recovery. Even people who had relapsed would remember something their
counsellor had said and take that phrase into their next recovery experience with a
deeper understanding of what was meant.
 In addition to being non-judgmental, a counsellor has to display humanity by
being empathic and communicating an understanding of the client’s experience.
That may sound easy, but it really is a skilled practice. There is nothing worse than
trying to explain your chaotic, messed up life to someone who has a blank look on
their face or clearly is not relating to anything you have to say. That is not to say the
counsellor has to be in recovery, or have had a chaotic life, although many people
felt that clearly helps. A counsellor simply must be able to offer more than
superficial responses and platitudes to be effective. Never use phoniness or fakery,
and don’t hide behind terms like “boundaries” or “professionalism.” Boundaries are
meant to prevent clinicians from becoming overly involved in a client’s life to the
point of
Chapter 2 A Client Perspective
37

being therapeutically detrimental. They were never meant to discourage humanity

from entering into a therapeutic encounter. Being genuine and human is the only
way to reach someone, and it can be achieved without sacrificing professionalism
or violating any boundaries.
Addiction is more than a set of behaviours. It is accompanied by deeply
personal, sometimes shameful, emotions and experiences. Demonstrating that you
are hearing more than just the words and can put yourself in the client’s life,
without absorbing it, helps the client feel you are someone he or she can work with
successfully.
When I was a student and first working with clients, I tried to emulate the
counsellors I was shadowing. I spent so much time trying to sound smart and adapt
to their way of doing things that I came across as awkward, detached and phony,
which is pretty ironic. It was only when I realized that I just needed to be genuine
and listen and respond to people as I would want to be spoken to that I was able to
relax and be present for clients to hear their stories and meet their needs.
Given the heterogeneity of the client population, clinicians need to be flexible
in their approach and include more than one style in their repertoire. Some clients
are looking for factual information; others want to tell their story; some want to hear
that the clinician can relate to what they are saying and give them validation, while
others are looking for a more intellectual approach. Using the same methods with
every client to obtain information, provide treatment options and conduct groups
will only reach a small percentage of your client group. Being able to adapt to what
is in front of you and what is needed for the situation is part of being a great
clinician.
Many clinicians tend to overlook something that is often not included in text
books on technique or clinical practice but that is essential to recovery. Hope. It’s
incredibly important to instil hope in your clients. Not the phony “attaboy, you can do
it” kind of hope, but the genuine offering that there is a better life out there and that
sticking with it will pay off and that you will help the client get there. I am an
example that it can be done, and I’m convinced that others can do it too. That’s not
to say it’s easy, it’s not, but it can be done, so I offer hope—always. Clients who
said they had a great counsellor spoke about the hope they felt when they were
with their counsellor. No matter how rough it got, their counsellor never let them
forget there is hope and never stopped believing in them. All clinician/client
interactions should be based on the expectation that the client can and will recover
and have a better quality of life (Cherry, 2008).

I couldn’t have done it without the others in the program.

 Some people talked about having good counsellors who played a pivotal role in
their recovery. Everyone talked about at least one other client, if not more, who
was a sig nificant part of the recovery journey. The power of a common experience
cannot be understated. Going through something so difficult with others who were
dealing with the same struggles played a monumental role in people’s stories.
Even if counsellors
38 Fundamentals of Addiction: A Practical Guide for Counsellors

have had their own personal experiences of going through treatment, they are not
going through it now; that is where other clients who are having the same feelings,
thoughts, fears and irritations can be helpful.
Twelve-step programs have always capitalized on the power of fellowship
and sponsorship (Narcotics Anonymous, 2004). Having another person to talk to
who is also in recovery, who has time to talk and listen, and who can share lessons
learned, steer you away from bad decisions and recognize warning signs if you are
about to relapse is an essential part of the self-help movement. There will be times
when clients may be fooling themselves, lying or overestimating their ability to stay
clean. Other clients can point out those things in a way that clinicians may not be
able to. Many programs that are not based on the 12-step model fail to capitalize
on this valuable resource. Some outpatient programs have rules forbidding clients
from socializing with one another or tell clients not to go for coffee or do things
together after group. Sometimes clients are told they can go for coffee but they are
not to discuss anything “personal” or talk about their recovery.
As a clinician, I understand the rationale. You don’t want clients working on
one another’s problems and trying to rescue one another; you want them to focus
on their own recovery. Clinicians also worry about clients triggering one another
and taking it badly if someone relapses. The thing is, clients do it anyway. It would
be better for people to have guidelines to adhere to when they socialize than to
sneak around and worry about being discharged from a program for making a
friend. Many addicts don’t have people in their lives to talk to who aren’t using and
they don’t know how to make friends with people who aren’t in treatment. Those
early steps toward making friendships while clean and sober are important steps
toward a new type of social development.

Ah, the system!

It needs fixing. That was the general consensus among people who had been
through treatment. It will come as no surprise to anyone in the addiction field that
clients think it is difficult to find a treatment program and have to wait too long to
get in. It would be useful if people seeking help had one phone number to call to
get information about treatment programs and options. Many clinicians are familiar
with the Drug and Alcohol Registry of Treatment (DART), but not many clients have
heard of it. Making information more accessible and readily available would help
clients or family mem
bers who need information about treatment. Some people felt it would be useful if
all facilities pre-screened clients right away, rather than making them wait a week
or more. When a client feels ready for treatment, there is usually a small window of
opportunity. Any small frustration, such as waiting for an appointment, can close
that window. Pre
screening clients when they first make inquiries about an appointment gives them
the opportunity to ask questions and get information, and takes some of the
mystery out of the process. This may help clients stay committed to keeping their
 assessment appoint ment, even if they have to wait.
Chapter 2 A Client Perspective
39

Clients with concurrent disorders are still particularly disadvantaged when it

comes to finding suitable treatment. Although they may be able to access more pro
grams than they used to, it does not mean they receive holistic care that addresses
all their issues. Even those who entered a concurrent disorders program felt their
mental health issues were not addressed sufficiently and they were encouraged to
get help for those issues within the mental health system only after they completed
addiction treat ment. If we conceptualize a concurrent disorder as two problems,
treat it as if it is two problems and tell clients they need to get treatment in two
different programs, what are their chances for recovery? They will either see the
situation as overwhelming and not want to deal with any part of it, or they will think
“I’ll deal with this now and deal with the rest down the road” because that is often
how staff present it to them. When a clini cian minimizes one issue or the other, the
client will too. But the fact is we don’t flick a switch and shut off one part of our
problems. Those problems interact and influence one another in powerful ways and
can affect the treatment experience and outcome. Advising clients to address their
mental health issues after they complete substance use treatment places the
obligation on the client—the most vulnerable person in the equation—to be his or
her own case manager. This simply sets clients up for failure.

Nothing about us, without us.

How often is client feedback sought in your organization? Aside from anonymous
sur veys that ask questions like “how satisfied were you with the group?” are there
ways to provide genuine feedback about the program and the clinicians working
within it? One person suggested that client feedback be incorporated into staff
performance evalua tions, which would certainly influence service delivery.
Meaningful feedback can only be sought through one-to-one interactions or safe
focus groups.
When I last managed a clinical program, I used to try meeting with clients
when they were being discharged to ask about their experience and discuss
suggestions for improving our program. Clients who were not comfortable talking
about their experi ence could complete an anonymous survey that allowed them to
voice any concerns or compliments, but usually they appreciated being able to talk
to a person. In my experi ence, clients often made observations about clinicians that
echoed opinions I had already formed from listening to clinicians speak in team
meetings and rounds. The client voice confirmed what I already knew—that I had a
superior clinician or I had some issues to address with training or supervision.
Clients also offered suggestions for the program that were often easily
implementable from an operations standpoint but that could only come from having
experienced the program as a client.
40 Fundamentals of Addiction: A Practical Guide for Counsellors

Conclusion
There are probably few people working in the system who think it works perfectly.
Most of us realize that the system often disadvantages clients in ways we feel we
don’t know how to change. But within individual programs, barriers can be lowered.
 How your program accepts clients, how quickly your program can accept clients
and what your program offers can always be improved. Communicating with clients
about what to expect and what the program is about will help them understand
what they are enter
ing into. Ensuring clinicians are well trained, well supervised and assisted with
practice difficulties can improve outcomes and clients’ perceptions of their
experience. Asking clients about their experience and having a mechanism for
them to offer feedback and suggestions can often uncover novel, inexpensive ways
to improve a program.
When clients come to us, they are looking for help. They are experiencing a
pro found realization that life cannot continue the way it has been, but that doesn’t
mean it will be easy to change or that it will be easy for the clinician. Clients have
the right to expect that clinicians will treat them with dignity, compassion and
respect, and have the skills to see them through this life change. They will often
challenge clinicians, but those who meet this challenge will have their clients’
lifelong respect and often inspire some to enter the field. The clinician who can
treat a client as capable and knowledgeable about his or her own life experience
will be able to form a genuine partnership through the client’s recovery journey.
Clients will relapse—that is part of recovery—but your personal response to
relapse should not be the deal breaker or your opportunity to make the client feel
inadequate. No one I spoke with who has had success with recovery ever thought
they would be successful. Usually, they had many failed attempts and were ready
to give up. But someone gave them hope and eventually made them feel they could
do it. To those people, whether professionals, laypeople or fellow members of the
recovery experience: thank you—from all of us.
Chapter 2 A Client Perspective
41
Practice Tips

• Remember that for your client, this is the scariest thing ever and it
seems impossible. Help clients see that you understand that, and
will help them get through it.
• Be non-judgmental and truly present for the client. Being mindful of
your body language, your tone and the internal thoughts that may
be coming to mind will help you do this. Remember, your client
can read you.
• Learn as much about mental health as you have learned about
addiction, and vice versa. Treat the whole person.
• Expect clients to recover and have a better quality of life. Offer them
hope. • Let clients know what they can expect from your program,
and from you. Let them know what might be available in the
community, should they be looking for something different.
• Have a mechanism for clients to offer open-ended feedback and
sugges tions about the program. Take their feedback seriously.
• Relapse means there is more work to be done and lessons to be
learned. That’s all.

Resources
Publications
 Carr, D. (2008). The Night of the Gun: A Reporter Investigates the Darkest Story of
His Life. New York: Simon & Schuster.
Maté, G. (2008). In the Realm of Hungry Ghosts: Close Encounters with Addiction.
Toronto: Random House.

Internet
Canadian Harm Reduction Network
http://canadianharmreduction.com
Drug and Alcohol Helpline
www.drugandalcoholhelpline.ca
LifeRing Secular Recovery
www.liferingcanada.org
42 Fundamentals of Addiction: A Practical Guide for Counsellors

References
Cherry, A.L. (2008). Mixing oil and water: Integrating mental health and addiction
services to treat people with a co-occurring disorder. International Journal of
Mental Health and Addiction, 6, 407–420.
Kaplan, C. & Broekaert, E. (2003). An introduction to research on the social
impact of the therapeutic community for addiction. International Journal of
Social Welfare, 12, 204–210.
Maté, G. (2008). In the Realm of Hungry Ghosts: Close Encounters with
Addiction. Toronto: Random House.
Narcotics Anonymous. (2004). Sponsorship, Revised. Van Nuys, CA:
Narcotics Anonymous World Services.

Chapter 3

Diversity and Equity Competencies

in Clinical Practice
Janet Mawhinney

Marc, a relatively new counsellor at the agency, is disheartened when a

client in a really vulnerable situation cancels his appointment. He is
even more determined than ever not to lose his next client, Aleah.
Aleah is a refugee who has been in Canada for less than a year. She
arrived with her two chil
dren, age 4 and 6, after fleeing her home country due to civil war.
Before arriving in Canada, Aleah and her children spent two years in a
crowded refugee camp, where they witnessed many acts of violence.
They are now struggling to adjust to a new life in Canada. Since
arriving, Aleah has begun to rely on alcohol and the benzodiazepine
Lorazepam (when she can get it) to deal with her difficulties, and she is
 struggling with her use.

In trying to engage with Aleah, Marc seeks out the advice of his
colleague Nagin, who is well respected for her work with marginalized
communities. Nagin encourages Marc to consider the social context in
which Aleah was liv ing, recognizing the impact of her life in her home
country, and the effects of migration. Nagin suggests that Marc also
think about how Aleah may have learned to mistrust authorities, and
that she has clearly experienced trauma and may feel unsafe and
unfamiliar seeking the help of a professional, par ticularly since she has
substance use issues that she might fear will cause her to lose custody
of her children.

Marc prepares by learning a bit about Aleah’s home country and

settlement issues to inform his engagement with her. He begins by
listening carefully and allowing Aleah’s trust to build gradually. He
reflects back to Aleah her evident courage and resilience in managing
the migration journey with her children, and her ability to get this far in
the treatment system. Marc reflects on his own social location and
cultural norms, and how being male, English-speaking, Canadian-born
and part of the health profession may affect his rapport with Aleah and
how to mitigate that impact to support Aleah in meeting her goals.
44 Fundamentals of Addiction: A Practical Guide for Counsellors

Diversity matters. It matters in the lives of clients, in the way services are
designed and delivered, in how health systems are structured and in the very
essence of how clini cians understand themselves and their work. The goal of this
chapter is to understand how we can effectively integrate a diversity and equity
lens into our professional practice as a core component of quality care. The
chapter is an introductory road map to the spe cific skills and knowledge required to
“do diversity” in addiction treatment.
Fortunately, there is a solid foundation of multidisciplinary research and prac
tice literature, and several decades of dynamic debates about models, frameworks
and approaches to draw on. The clinician is often highly motivated to “get it right,”
while at the same time fearful of getting it wrong. The question is, how do we move
from inten tion to action, from research to practice? How do we bring the necessary
knowledge and skills to bear to translate diversity and equity principles into clinical
practice with diverse clients, applying a wide range of cultural perspectives on
substance use?
Integrating diversity strategies into treatment and building equity and cultural
competence into service models and systems certainly requires specific knowledge
and skills. But implementing these concepts also builds on wisdom and capacities
that are foundational for most clinicians. This work is about implementing the
distinct but interrelated concepts of diversity, clinical cultural competence and
health equity. In the practice literature, these concepts are often framed as
relatively independent from one another, rather than as existing on a dynamic
continuum, with each informing the other. In fact “doing diversity” in clinical practice
draws on all three domains or concepts, apply ing a combination of awareness,
knowledge and skills to achieve effective and equitable care outcomes. Rather
than the onus being on clients to make themselves understood to the therapist,
therapists can work to educate themselves and respond sensitively to the diverse
needs of their clients, as the opening case study illustrates.
 Diversity
At its weakest, diversity refers to differences removed from social context, a
concept as banal as, “I like blue, you like yellow, we’re all just people.” From a
social determinants of health lens, it’s clear that diversity is not about “difference”
per se, but about unequal power in society—both historically and today—operating
across key social locations, including race, ethnicity, gender, class and
socioeconomic status, sexual orientation, dis
ability, language, accent and gender identity. Diversity in the health and human
services context is about the impact of inequality on the health and well-being of
marginalized individuals, communities and cultures.
Most health practitioners will be familiar with the significance of the social deter
minants of health to this definition of diversity. The categories of the social
determinants of health are dynamic, but include income level and distribution,
housing, employment, social exclusion and more recently, forms of oppression
such as racism or ableism that in and of themselves are seen as social
determinants of health (Mikkonen & Raphael,
Chapter 3 Diversity and Equity Competencies in Clinical Practice
45

2010). In the context of health, diversity is about how these characteristics of social
locations affect and even largely determine health risks, access to service and
overall health status. It is well recognized that populations with greater challenges
in sustaining good health and in accessing housing and employment have a higher
burden of illness and poorer health outcomes (Braverman, 2006). Plainly put,
poverty, discrimination, social exclusion and stigma are bad for our health. Applied
to addiction treatment, this reflects the need for a holistic approach that recognizes
the effect of non-clinical factors on health and that acknowledges the many ways in
which people view, understand and engage in recovery. A holistic approach also
recognizes the importance of having access to adequate resources and life
options.
The definition of diversity engaged here includes all the categories recognized
by human rights codes and the Canadian Charter of Rights and Freedoms and
related leg islation, but is not limited to these. At the big-picture level of social
structures, Canadian human rights laws are a vital component of “doing diversity,”
even if it is not always top of mind in clinical work. It is an under-appreciated fact
that our highest level of law explicitly recognizes the need for the protection of
minority rights and the de facto exis tence of histories of discrimination that have
systemically disadvantaged specific groups in particular ways. (One need only do a
quick Internet search for examples of systemic discrimination toward Chinese
1
Canadians, Japanese Canadians, women, Aboriginal and First Nations Peoples,
various faith groups and people with mental health or addiction issues, for
example.)
Entrenching the concept of “designated groups” and “prohibited grounds” of
discrimination in human rights law creates a fairly unique system in which positive
measures taken to redress historical wrongs and mitigate their current expressions
are understood as acceptable and often necessary, and do not constitute bias or so
called reverse discrimination. For example, a positive measure such as hiring
female clinicians to work with women victims of abuse or a program prioritizing
Somali- or Arabic-speaking staff to work with members of the Somali community
constitutes an expression of our human rights laws—not a breach of them. A
structure or program design that is aimed at mitigating the impact of racism—for
 example, by integrating Aboriginal cultural practices within an Aboriginal addiction
treatment program or prioritizing the hiring of skilled Aboriginal staff in a
mainstream service—does not create a “reversal” of colonialism and racism. The
perspective behind the term “reverse discrimination” grossly distorts the impact of
decades-long systemic discrimination (including through formal government and
institutional policies, laws and processes) and decontextualizes initiatives aimed at
preventing and addressing discrimination. The term re-centres the focus on the
status quo of established privileges and hierarchy (be it gender, race or class). If
only a micro-level intervention such as priority hiring would actually reverse macro
social and historical systems of oppression, full equality would

1 While the term “Aboriginal” is frequently used as an umbrella term for First Nations (status and non-status), Métis and
Inuit, many First Nations reject the term as failing to recognize the distinct rights of each of these groups. This is
particularly so since the Department of Indian Affairs and Northern Development was renamed the Department of
Aboriginal Affairs and Northern Development Canada in 2011. For more information, visit
www.chiefs-of-ontario.org/faq. The author generally uses the term “Aboriginal,” but wishes to recognize the critique and
the dynamic nature of debates around naming language.
46 Fundamentals of Addiction: A Practical Guide for Counsellors

be readily achievable! Surprisingly, federal and provincial laws are occasionally

more progressive than some front-line staff and managers who may struggle with
the notion of customized strategies in service design or delivery aimed at
addressing barriers for specific populations or communities.
A core principle of diversity and health equity is the fundamental recognition
that treating everyone the same does not result in equal outcomes. We don’t begin
from a level playing field and one size does not fit all. If the goal is to ensure equal
opportunity for services and more equitable health outcomes regardless of identity
or social location, then we need differential, customized treatment to address
barriers to health care.
The demands of a broad human rights–based definition of diversity can seem
daunting at first, but perhaps counterintuitively, this complexity is also one of its
great strengths. Understanding diversity to include a range of social locations and
identities means that each one of us has some wisdom, knowledge, expertise and
lived experi
ence of at least several of these identities: our ethnicity, gender, language and race,
for example, inform our perspectives. Equally important, understanding diversity is
about recognizing that each one of us has areas where we lack knowledge of
different identi ties and social locations. Every service provider has a potential point
of engagement with the issues of diversity and equity, some expertise and
something new to learn. We are all multiply located. However, the integration of an
analysis of systemic inequality, oppres sion and privilege is essential to this
understanding of multiple diversities and human rights. When engaged effectively,
these multiple points of knowledge assets and learning gaps can be a powerful
component to a diversity competence strategy in clinical service.
This broad definition of diversity, which integrates anti-oppression rather than
mere “difference,” avoids the problems of a rainbow of identity relativism, which
conveys that “we are all diverse,” while absenting material inequality. This stance is
expressed through comments that someone “doesn’t see” race, colour, gender or
ability, despite the evidence that such differences do matter. Rather, the broader
definition enables us to reflect on the impact of unequal social power in each of
these identities and makes visible the systemic, entrenched and institutionalized
nature of privilege and marginal
ization. Practitioners and clients need to understand how inequality and inequity
affect clients’ health in order to develop meaningful strategies and interventions.
Understanding power dynamics is about mapping degrees of privilege and mar
 ginalization across and among each of these aspects of diversity. The fact that most
of us have areas of privilege and areas of marginalization in our lives means that
we have to pay particular attention to how specific power dynamics are expressed
in any given situation, be it within a team, clinical service delivery or program
design, or at the orga nizational level.
While each of us has experience with some unique combination of privilege and
(for most of us) marginalization and multiple points of engagement with these
issues, it is easier to remain blind to our own privilege, which by definition
smoothes our path ways. Privilege is the absence of barriers, proximity to
established norms and the accrual of unearned benefits. In clinical practice, it is
important to recognize how our privilege is
Chapter 3 Diversity and Equity Competencies in Clinical Practice
47

at play in the workplace and in the therapeutic relationship. In order to create safe
spaces for clients, therapists may need to unpack the role of privilege and
oppression in their relationships. At the very least, actions of the therapist must not
reinforce or replicate oppressive patterns that may contribute to clients’ presenting
issues.
For the practitioner, this means that living with one or two points of
marginaliza tion, for example, female gender and lesbian sexual orientation, should
not make one blind to or disengaged with points of privilege such as white skin,
class and ability. In practice, these issues require a process of learning, critical
reflection and a dynamic engagement within a complex social context. For
example, a white middle-aged hetero sexual nurse with 25 years of experience in
addiction and sexual health work in large cities may have impressive skills and be
highly culturally competent working from a harm reduction model with urban gay
male communities, but will have a whole new learning curve in providing service for
urban and suburban heterosexual women of colour at risk for HIV.
Bringing historically grounded evidence of inequality and current health equity
data to our understanding of marginalization and privilege enables us to appreciate
the particular salience of some issues or combination of issues to health status,
such as intersections of gender, race, class and immigration. This information can
be a power
ful clinical tool. The last two national census results, for example, reveal that
poverty is highly racialized, in that populations with the lowest income are recent
immigrants (five years or less), Aboriginal Peoples, racialized people and people
with disabilities. If we were to analyze the data further we would also see the
gendered racialization of poverty within these communities (Block, 2010; Statistics
Canada, 2011). This data can tell us which communities are at greater risk for poor
health and can inform planning for health promotion, access to treatment and
program design. “Doing” diversity means having the awareness of power and
social location (of self, team, service and client or community), combining this
awareness with knowledge of health data for specific populations and bringing that
awareness and knowledge to bear in practice (the skills component). Health equity
knowledge broadens the clinician’s understanding of the cli ent’s social context to
yield options that are realistic and meaningful for the client.
How we “see” and meaningfully practise diversity is both obvious and
complex. Diversity can be both visible and invisible—the more visible often being
race, sex, gender expression, age, some physical disabilities, ethnicities (at times)
and some languages. Some diversities, including sexual orientation, class and
socioeconomic status, may vary in visibility based on factors such as individual
expression and the social context, including the class and gender norms in a
 service, organization or community. Working with front-line clinicians across the
province, I have often been struck by the frequency with which diversity is assumed
to refer exclusively or primarily to race and ethnicity (narrowly defined). Training in
northern and northwestern Ontario, I have commonly heard “Oh, but we don’t have
much diversity here,” as if the ethnoracial and immigration realities of southern
Ontario and the Greater Toronto Area are the only true examples of diversity.
48 Fundamentals of Addiction: A Practical Guide for Counsellors

While it is essential to attend to the persistent relevance of race, ethnicity and

immigration to health disparities, reducing diversity to these three issues can be
limiting to inclusive service provision. For clients coping with addiction issues, a
range of other challenges can also arise—around literacy; age-related issues
(particularly for youth and older adults); stigma regarding mental health and
addiction; sexism; marginalization of lesbian, gay, bisexual and trans people;
barriers for people with disabilities (especially transportation and access to
services); violence against women; marginalization of and racism toward Aboriginal
and First Nations communities; and underlying poverty and social isolation. A well-
prepared health professional needs to appreciate equity issues that intersect and
span a continuum of identities and social systems. A systemic, broad and
intersectional comprehension of diversity and power is thus critical to this work.

Health Equity and Its Relationship to Diversity

Having laid a foundation for a broad, intersectional and human rights–based under
standing of diversity, it would be helpful to map out how this concept of diversity is
related to health equity, a term less familiar to some, but increasingly central to the
health sector, addiction services and equitable health strategies.
Many health and social services are adapting their diversity statements and
poli cies to incorporate the language of health equity. Significant convergence exists
between models of diversity I have outlined and the concept of health equity. One
of the most cited definitions of health equity is “differences in health that are not
only unnecessary and avoidable, but in addition unfair and unjust” (Whitehead,
1992, p. 431). Health equity addresses health outcomes that are not biological or
genetic, but are the result of social systems and structures, and are thus avoidable
and changeable, such as low birth weights for infants in poorer families, high rates
of diabetes in Aboriginal communities or injury and trauma due to domestic
violence.
Health equity is about understanding the ways in which disadvantaged social
groups—such as the poor, racial and ethnic minorities, women, trans people,
people with disabilities or other groups that have persistently experienced social
disadvantage or discrimination—systematically experience worse health or greater
health risks than more advantaged social groups. Health equity puts a focus on
disparities in access to quality care and health outcomes—and thus has more of an
emphasis on what can be measured and demonstrated than diversity strategies
have tended to have. Pursuing health equity in clinical care means advocating for
and working toward the elimination of such health disparities and inequalities.
Broadly speaking, a health equity strategy would seek to measurably reduce gaps
between the most socially advantaged and those who are not, including in
incidence of chronic disease (e.g., diabetes, asthma, arthritis), premature death,
injury, victimization by violence, as well as health system indicators, such as
reduced wait times, accessing service before reaching an acute state, better spe
 cific health outcomes, and culturally and linguistically appropriate services.
Strategies
Chapter 3 Diversity and Equity Competencies in Clinical Practice
49

might focus on access issues, program design, clinical education and capacity,
evaluation of service response, ensuring that service delivery is not contributing to
the problem (health care inequities) and considering health outcomes for diverse
clients.
Health equity in addiction services includes the willingness and capacity to
work with and across identities one might not share. This includes the capacity to
address one’s individual bias, prejudice or ignorance of particular groups (e.g.,
refugees, a spe cific faith or ethnic group) or social issues (e.g., poverty, domestic
violence) and ensuring these limitations do not affect clinical care. Working across
diverse social locations involves the ability to navigate potential discomfort and
awkwardness in our own learn ing. But if we take seriously the human rights
foundation discussed earlier, we cannot simply rest with our biases and say “I am
not okay working with ‘x’ population or com munity.” Rather, we need to consider
how we build capacity at the practitioner, program and system levels so that we are
mitigating, not contributing to, health inequities. At the system level, population,
community or issue-specific services are of course important, but we also need
broad-based services that effectively provide care for all.
One example of how diversity and health equity knowledge might be applied
in addiction service provision would be a readiness to work with lesbian, gay, bi,
trans or queer (LGBTQ) clients regardless of one’s own sexual orientation and
gender identity. In this instance, the practitioner should have some knowledge of
health equity research that shows higher rates of suicidality, addiction and some
mental health issues (depression and anxiety) as a result of social exclusion and
stigma toward the LGBTQ community (Buttery, 2004/2005). The practitioner might
bring an awareness of the impact of gen
der and age differences within LGBTQ health disparities research, as well as
awareness of the differences in prevalence rates among diverse LGBTQ people.
Bringing health equity data and research to bear is of course not about projecting
the socio-demographic health research onto the client, but about keeping this
social context and health data in mind when learning about the client’s specific life
context.
For clients who are also minoritized on the basis of race or ethnicity,
practitioners could explore how family, community and cultural resources are
important in dealing with both racism and homophobia. When assessing resilience,
risk and protective factors, social resources and sense of community, recognize
that many racialized LGBTQ people are part of multiple communities and cultures
and that these identities affect their wellness strate
gies. For some LGBTQ people, socializing in bars and clubs is an integral part of
connecting with community—so strategies to deal with alcohol and other drug use
must address ques tions of culture, identity and support in ways that are specific to
the client’s experience with the queer community. This exploration includes
defining family and identifying where sup ports and social resources are found for
the client. The client’s other aspects of diversity also remain integral to the recovery
process: disability status, mental health, literacy and socio economic resources are
all factors that shape the social determinants of health and identity strengths for
clients. This is about bringing a diversity lens to the process, not assuming the
primacy of diversity over other aspects of holistic identity, such as a person’s
interests and talents; being a parent, sibling or guardian; or their life journey and
 goals.
Fundamentals of Addiction: A Practical Guide for Counsellors
50

If we consider gender, another component of the diversity spectrum, the

knowl edge component for the clinician might include understanding that gender
power relations are universal and vary only in the extent or degree of inequality and
the specific expression or manifestation across geographic, cultural, generational,
national and other lines. According to the Public Health Agency of Canada (Sen et
al., 2008):

Gender power relations are a root cause of gender inequality and are
among the most influential of the social determinants of health. They
determine whether people’s health needs are acknowledged, whether they
have control of their lives or their health and whether they can realize their
rights. (p. 2)

This gender knowledge would include information about the clients and one’s
own beliefs and expectations about gender role norms. It could also include
accessing epidemiological data about the impact of alcohol and other drugs on
women compared to men; research on prevalence of trauma and linkages with
substance use; risk of intimate partner violence or other potential impacts of sexism
and gender inequality; and perhaps information about what groups are
disproportionately represented among street-involved women and the criminal
justice system (Aboriginal and First Nations women, lesbian, bisexual and trans
women). Gender equity would also include moving beyond gender as solely binary
male/female to include a spectrum of gender identities and expressions. This would
include gaining knowledge about the trans community, the prevalence of barriers to
accessing health and social services for trans people and the significantly
heightened risk of violence and social isolation (and under what conditions this is
most pronounced) (Trans PULSE Project Team, 2012).
This equity knowledge provides a rich social and political context for service
provi sion, but it is never to be engaged in a deterministic or prescriptive way. In the
face of this complexity, it is understandable to wish for a checklist or a single tool to
help translate knowledge into practice. But there is a good reason to resist this
impulse. Simply put, to reduce the realities of social location and power relations,
histories of colonialism and resistance, or culturally specific knowledge to a
checklist risks losing much of the meaning and knowledge needed to translate this
information into effective practice. Minimizing the impact of culture, diversity and
social location for an individual client in the face of the complexity of a person’s
actual life does a tremendous disservice to that person. Such an impulse is really
asking clients to leave some parts of themselves at the door, with all the potential
capacities and resiliencies therein, for the convenience or comfort of the service (or
service provider). Yet who hasn’t heard, “Can’t we just focus on gender and deal
with race somewhere else,” for example, or “We’re all here about our addiction
issues. Your immigration issues are not the point.” We want people to bring their
whole selves to the recovery process and this means having some capacity at the
system, program and prac titioner level to integrate the multiple diversities each of
us embodies.
The approach to diversity and health equity described here can act as a
framework that can be applied in any context. The foundational concepts remain
relevant across spe-
Chapter 3 Diversity and Equity Competencies in Clinical Practice
51
 cific situations because at the core is the recognition that the issues of power,
inclusion and diversity are never static, but are context dependent and dynamic.
Thus, we need a foundational understanding of power and inequality and, at the
same time, openness to the specificity of particular regions, communities and
histories—and the unique ways in which an individual negotiates and navigates
these realities. This is why there is no checklist for diversity inclusion and health
equity, no recipe for cultural competency in clinical practice.

Cultural Competence in Clinical Practice

We all want to have the ability to respond sensitively, respectfully and effectively to
clients and families in all of their diversity. The ultimate goal is for a practitioner,
team and agency or service to apply equitable, effective and culturally appropriate
knowledge and skills, in other words, competencies, into clinical work. This means
we need a frame
work to understand how we do that and the engagement, creativity and
organizational support to deliver services in a culturally competent and equitable
manner. At its best, clinical cultural competence is a method to move this
framework from idea to practice. Practitioners’ genuine interest in meeting the
needs of diverse populations is a positive driving force to tackle this potentially
complex terrain.
Clinical cultural competence is about the application of culturally appropriate
knowledge and skills in clinical work. More than 40 years of literature exists on
cultural competence in the health field, while precedents in anthropology,
behavioural sciences and organizational theory have been written about even
before this time. Cross (as cited in Gilbert, 2002) offers the most widely cited
definition in the literature: “Cultural com
petence is a set of congruent behaviours, attitudes, and policies that come together
in a system, agency, or among professionals and enable that system, agency or
those profes sionals to work effectively in cross-cultural situations” (Cross et al.,
1989, p. iv).
One underlying premise of cultural competence is that most clinical
encounters are cross-cultural in some way—especially if you consider a broad
definition of culture and the diversity and marginalization and privilege within
cultural groups (e.g., genera tion, income, disability, education, gender);
furthermore, many people are in themselves “multicultural” and multiply diverse in
heritage, ethnicities, nationalities, as well as cultures of youth/age/life stage.
Culture in this view is not a single variable; rather, it is a dynamic concept, with
multiple characteristics. Some researchers argue that many health practitioners
have little training in the social and behavioural sciences in which concepts of
culture and its reflection in attitudes, knowledge and behaviour are studied (Gilbert,
2002). And there are those who think that good technical skills are sufficient for
clinical cultural competence. As we shall see, good clinical practice is a necessary
foundation, but is not synonymous with or sufficient for clinical cultural competence.
Clinical cultural competence requires good clinical skills, a diversity and power lens
and cultural awareness applied to practice.
52 Fundamentals of Addiction: A Practical Guide for Counsellors

The fields of diversity in health and human services, health equity and cultural
competence are dynamic and evolving. Multiple theoretical and practice frameworks
exist within the cultural competence literature. It is beyond the scope of this chapter
 to delve into the differences between models of cultural sensitivity, humility, safety
and awareness within, broadly speaking, the cultural competence field. But within
the cultural competence field, a stream of clinical cultural competence work exists
that centres power and inequality within the model and brings a rich non-static
analysis of culture and meaning production to bear: this is the model engaged
here. As with the terminology for diversity discussed earlier, we have to interrogate
how the concept of cultural competence, or a particular iteration of it, is being
applied. In particular, the term “cultural competence” has been critiqued for bringing
an overly simplistic, ahis torical and depoliticized understanding of culture,
effectively producing the very sort of cultural checklist and stereotypes I am
warning against. This essentialist approach assumes an overly simplistic
understanding of culture and indeed of individual and community negotiation of
culture that is fixed and ahistorical. This simplistic model owes much to the world of
global business, which seeks simple rules for customs, such as greeting by
handshake or bow, or a trait list of how “x” people behave, eat, live or otherwise
conduct themselves.
Remnants of an apolitical and essentialist lens on culture still linger in the
equity literature, which is why some practitioners remain uncomfortable with the
term. Others dislike the language of “competence” for its potential to quantify
complex work as if one either is or isn’t competent. Early models also focused
exclusively on “the other” without a consciousness of the practitioner’s (and the
health system’s) own cultures. Clinicians are now less likely to draw on these
simplistic models, which have been heartily critiqued in the field of cultural
anthropology, where paradigms of cross-cultural work originated (Carpenter-Song
et al., 2007). It will be interesting to see how health and human services address
issues of culture over the next few years as the research, application to practice
and discussions continue. While it is vital to guard against a problematic
essentialized version of culture and cultural competence, there is a robust body of
work that does not operate from those paradigms.
Interestingly, a health care cross-disciplinary review of best practice literature
and regulated health professional colleges (nursing, social work, occupational
therapy, psychology and psychiatry) reveals that while there is a lack of an
operationalized defini tion in the literature, there is significant overlap of
understanding about clinical cultural competence (Harmaans, 2003). These health
disciplines all recognize three main com petence areas for clinical cultural
competence: awareness, knowledge and skills. They also agree on several key
features of clinical cultural competence, that it: • is highly valued
• is understood as an ethical responsibility
• is developmental and requires ongoing learning
• ought to focus on client-system outcomes and client perceptions
• is a key aspect of client-centred care.
Chapter 3 Diversity and Equity Competencies in Clinical Practice
53

However, what is missing or less explicit across the disciplines is the need for
social power relations and health equity to be central to clinical cultural
competence. An explicit integration of power and equity within clinical cultural
competence is a more recent iteration in the literature, but one that is central to this
project.

ABCDE Framework for “Doing” Cultural Competence

Providing a framework for clinical cultural competence can enable us to understand

 the key domains in this project and help practitioners integrate this skill within their
practice toolkit. This is necessarily a brief introduction and overview, not a
substitute for a more sustained and extensive engagement with the literature.
Srivastava (2008) has reconfigured and expanded the widely recognized core
domains of attitudes, knowledge and skills required for cultural competence as the
“ABCDE” of clinical cultural competence—affective, behavioural, cognitive,
dynamics of difference, and equity and environment. This is a brief introduction to
these core domains.
The affective domain refers to cultural awareness and sensitivity, an
understand ing of culture and its impact on values, norms, world view and
communications. This should be applied self-reflexively to one’s own culture and
social location and also to the culture of one’s discipline, agency or organization
and cultural view of health and illness. This domain is closely linked with the
“cultural humility” model (Tervalon & Murray Garcia, as cited in Kirmayer, 2012).
The behavioural domain refers to skills applied in practice at all stages of
service provision, including engagement, negotiation, support, care planning,
referral and closure, which enable the health care provider to integrate the client’s
cultural milieu, social power issues and self-reflective practice regarding the
clinician’s own “culture” (broadly defined), in order to engage with the client for the
most appropriate goals and interventions. According to Srivastava (2008), “The
behavioural domain of cultural skill is complex as it requires competency in the
domains of awareness and knowledge along with ‘knowing how’ to provide
effective care across cultures” (p. 27).
In the cognitive domain, Srivastava (2008) emphasizes two forms of
knowledge essential for clinical cultural competence—generic cultural knowledge
and specific cul tural knowledge.
Acquiring both generic and culturally specific knowledge is one aspect of
clinical cultural competence that has not overlapped significantly with the previous
discussion of diversity and health equity. This domain of knowledge is essential to
effective cross cultural clinical work, and comprises one of the final key concepts for
integrating “the how” of diversity in clinical practice.
54 Fundamentals of Addiction: A Practical Guide for Counsellors

Generic cultural knowledge

Generic cultural knowledge refers to universal components of culture and includes
understanding what culture is; how it operates; what makes for culturally influenced
communication styles (e.g., high context to reflect when unspoken information is
being communicated implicitly versus low context, when information is being
communicated explicitly); and predominant world views, such as
independence/interdependence, autonomy/community, body/mind/spirit separation
or integration, fatalistic/willful and so forth. Generic cultural knowledge can be
learned and developed over time, but once a foundation has been learned, it can
be applied across all cross-cultural work in a dynamic and reflexive way to
understand the unique and myriad ways in which these components of culture can
be expressed. This includes the necessary ongoing reflection of one’s own culture
and dominant norms, beliefs and practices within the health setting and system.

Culturally specific knowledge

Culturally specific knowledge is the ongoing process of learning about specific
cultures (again broadly defined) and combinations of cultures that are relevant for
the clients and communities you serve (e.g., Aboriginal urban youth, Tamil older
 adults). By definition, culture, communities and individuals are not static, so this is
where the “work” of learn
ing is never done. In “doing” cultural competence, just as with “doing diversity,” it is
not possible for any one individual, program or agency to become fully culturally
competent for all cultures with the intersections of various diverse social identities
therein, or even within one community. The practice of clinical cultural competence
requires ongoing learning about specific cultures in varying social and historical
contexts and exploring what this may mean for individual clients.
Where and how do we acquire culturally specific knowledge? This is really a
ques tion of how we learn about the people and communities we serve, but adding
a focus on culture, diversity and equity. Health service providers typically use many
strategies to learn about the communities and clients they serve; culturally specific
knowledge acqui sition is just an added component of that practice skill.
There are myriad avenues for learning about the nuances of cultures,
including: • reviewing existing research (population health studies, public health
research, Statistics Canada health reports, advocacy research, epidemiological
research) • engaging with the community and community-based agencies or
coalitions (partner ships, service agreements, formal and informal relationships)
• participating in structured education (courses, in-services, work
exchanges) • listening to your clients and their collaterals
• researching historical and current events affecting the community (e.g.,
awareness of the residential school system in Aboriginal and First Nations
communities, cutbacks to refugee health resources, shifts in immigration
patterns and settlement)
• exposing yourself to literature and film and participating in community events and
festivals
Chapter 3 Diversity and Equity Competencies in Clinical Practice
55

• using team meetings, supervision and other existing forums within the clinical
setting to share information and exchange knowledge to build capacity within the
service.

Health care providers should not rely solely or primarily on the client for cultur
ally specific knowledge. Marginalized clients and those whose identities are
different from the clinician or from mainstream health care often experience the
extra burden of educating the clinician in order to receive appropriate care. On a
very practical level, this eats into the time the client has for himself or herself. As
one client has said, “You only get 10 minutes at a physician for the most part and if
you have to spend half of it explaining to them what’s going on, you don’t get your
services” (Eady at al., 2008). Part of this project must be to develop strategies to
support ongoing learning and knowledge exchange within organizations as part of
the organizational competencies.
Srivastava’s (2008) “dynamics of difference” and “equity and the
environment” are about ensuring that principles of human rights, diversity and
health equity are engaged with throughout the process at the client-clinician
interaction level, the client program/service level and the broader health system and
societal level.
The cultural competence literature discusses multiple levels of engagement,
including the micro or individual level, the meso team or program level and the
macro level, both organizational and societal. As Srivastava (2008) emphasizes,
clinical cultural competence cannot function without organizational support, no
matter how motivated and informed an individual service provider may be:
“Individual healthcare providers need organizational resources such as interpreter
 services and collaborative partnerships with community agencies for purposes of
referral and consultation” (p. 29). This multi
level engagement comprises the equity and practice component of Srivastava’s model.

Relationship between Diversity, Health

Equity and Cultural Competence
The interconnections between the foundational concepts of diversity, health equity
and cultural competence are critical to the conceptualization, system design and
practice expectations of health services and have been a major focus of this
chapter. Diversity includes the multiple and intersectional operations of power and
privilege at the individ
ual, institutional and systemic levels. Health equity then considers how diverse
identities and social locations affect health status, which brings an emphasis on
outcomes and measurement in how we deliver health services. Health equity
provides a framework to bring diversity awareness into health deliverables. Clinical
cultural competence, in turn, can be understood as a specific set of practices in
service design and delivery, based on an awareness of culture, diversity and
power, engaged to support equitable health out
comes. In other words, cultural competence is a practice strategy to reach health
equity goals informed by a diversity lens.
56 Fundamentals of Addiction: A Practical Guide for Counsellors

Nuances in Practice
This chapter has provided an introductory map to the foundations and intersections
of diversity, health equity and cultural competence in clinical work. At its core, this
approach is about integrating a holistic approach that sees diversity and culture for
both their potential risk and protective factors, viewing the client as the expert on
his or her own life, demonstrating respect and regard for the client’s world view,
ensuring client-led treatment planning and being able to engage culturally specific
and alternative therapies.
In practice, application of this approach will look different with every client. In
the case example that opened this chapter, we were introduced to Aleah, who fled
civil war with her two young children and came to Canada after two years in a
refugee camp. In engaging Aleah and beginning to build a therapeutic relationship,
her counsellor, Marc, considers the social context in which Aleah was living and the
impact of pre-migration, migration and post-migration factors, including why Aleah
might mistrust authority and state systems, the impact of trauma (including risk of
sexual violence), the fear of losing custody of her children, her struggle to navigate
the Canadian health system and perhaps her lack of familiarity with the role of the
clinician in that system. Clinicians may also benefit by soliciting clients’ explanatory
models of their situation and addiction issues from a holistic perspective (Kleinman
& Benson, 2006; Kleinman et al., 1978). In the case of Aleah, Marc reinforces
Aleah’s strength and resilience evident in managing the migration journey with her
children, her parenting capacities, and her ability to engage with housing, income
support and the treatment system. Marc also obtains specifics about Aleah’s
culture and socio-political realities to help build rapport and provide appro priate
care, and to help her navigate Canadian health policy and systems issues, which
have been affected by federal cuts to refugee mental health, preventative treatment
 and childhood vaccinations (under the Interim Federal Health Program in 2012).
Marc also reflects on his own social location and cultural norms, and is mindful of
the gender, linguistic, ethnic and other diversities at play in the treatment process.
A fuller profile of equity engagement in practice would consider the structures and
supports at the team, program and service levels as well. These are just a few of
the many possible ways in which equity competencies could be applied with Aleah.
As discussed earlier, it is important to guard against stereotyping, essentializa
tion or reducing a person to a cultural profile when working cross-culturally. A
vigorous equity and client-centred orientation means that the clinician is always led
by what is true for a particular client, not what might be a general truth for his or her
culture or community. Lieninger (as cited in Srivastava, 2008) describes this
culturally specific knowledge as “holding knowledge” of cultural patterns that the
clinician has on hand to inform the engagement with the client, but not in a
prescriptive manner. For example, the fact that some Aboriginal and First Nations
cultures may communicate with pauses and less direct eye contact does not mean
a particular client will. In the same way, the fact that some first-generation
immigrants from a particular region may subscribe to traditional gender norms does
not mean that your client or her husband from the same
Chapter 3 Diversity and Equity Competencies in Clinical Practice
57

region will share these same perspectives. As a test of this, research your own
cultural profile and reflect on the extent to which it resonates for you as an
individual. Culture matters profoundly, but it is not deterministic.
For some dominant culture practitioners, learning about histories of
colonization and racism may trigger an unhelpful guilt response that will need to be
navigated in the therapeutic relationship. This can translate into counter-
transference or boundary issues, such as needing the client to educate or absolve
the clinician’s sense of guilt. Newly acquired knowledge of histories of oppression
occasionally translates to a focus on a static or rigid view of the impact of structural
oppression on the client to the exclusion of the client’s coping skills, resistance
strategies and individual negotiation of the social and political world. This can be
limiting to the client’s sense of agency, autonomy and resilience and to the
meanings the client has created in his or her own personal narra tive, and risks
slipping into a deficit model of marginalized cultures. There is a balancing act in
bringing an awareness of the historic and systemic legacies of oppression and the
self-reflection of one’s own culture and contexts, while being led by the client’s
unique world view and orientation to the situation.
The integration of diversity and equity into clinical practice involves
engagement at the micro or individual level, the meso or program/agency level and
the macro or health-systems level. To be truly effective in this work, practitioners
need adequate support and leadership. But at the same time, we can also break
the work down into manageable goals. While this chapter is anchored in macro or
big-picture issues of social inequality and health impacts, we also need to consider
what is meaningful for a particu
lar client. What are the things you can actually do something about? What is within
the scope of your practice? This same question can be asked at the team or
program level. This dynamic movement between big-picture analysis, concepts and
knowledge and the unique particularities and specificity of clinical work is an
important component of how diversity comes to life in clinical care. We should
always be led and encouraged by the potential to have a positive impact when and
where we can. And this, for many, is what also inspires and engages us in the
health care and human services fields.
 Organizational Considerations
Turning to the agency or organizational (meso) level, a useful strategy can be to
consider the cultural and other diversity assets of the organization at the program
design, policy, partnership and staff-capacity levels. Organizational competencies
can include organiza tional values, governance, planning and evaluation,
communication, staff development,
organizational infrastructure and service interventions (Kirmayer, 2012). Diversifying
the staff complement and leveraging the wisdom and insights of staff from
marginalized communities is one strategy to increase organizational capac ity. Are
staff from marginalized communities positioned to influence the agenda? Are their
perspectives valued and heard within the agency or service? This of course does
58 Fundamentals of Addiction: A Practical Guide for Counsellors

not mean hiring for identity per se, but for the skills and specific knowledge that is
pro duced from the margins. At the same time, it is not feasible for services to
continually match the shifting diversity of the populations they serve. Even when
there is similarity of diversity (be it class, ethnicity, race or gender) between the
service provider and the client, that does not create an inevitable similarity of
perspectives or an optimal thera peutic match for that particular client. Further, staff
from marginalized communities cannot be the sole bearers of the diversity and
cultural competence agenda. Relying primarily on staff from marginalized
communities places an undue burden on them while simultaneously letting staff
from more dominant cultures or privileged identi ties off the hook for this important
work. This is not a desirable situation and would eventually stall or sabotage efforts
to provide more inclusive, equitable and culturally relevant services. A diversity
asset audit would thus include the wisdom and skills of marginalized staff from their
unique perspectives as the diversity and equity capacities and skills of more
privileged staff, as well as the system and program design compo nents. Thus
education and capacity building of all staff is a core equity asset. The work of doing
diversity and clinical cultural competence should be understood as an integral
component of providing excellent care for all, and thus should be integrated within
all aspects of service design and delivery.

Conclusion
This chapter has discussed the foundational concepts and critical skills for “doing
diver sity” in clinical practice, and framed these skills as essential to quality care. In
thinking about “the how,” we have seen that there is no single checklist for a clinical
practice that integrates a diversity analysis and cultural competence in order to
achieve equitable health outcomes for clients. However, this explication of
concepts and frameworks provides markers along the way to guide us as we
engage in the ongoing process of understanding core equity domains and their
application to practice.
In practice, some of the skills required by the practitioner include critical self
reflection and an awareness of personal and cultural values, norms and biases,
including concepts of health and illness and the health system. We have seen that
it is important to bring an awareness of social location, power and privilege and a
commitment to miti gating their impact in service delivery. In the therapeutic
relationship with clients, the work requires knowledge of specific cultural norms and
the historic and socio-political realities affecting the culture or community as both
 risk and protective factors. We need to genuinely appreciate clients’ culture and
diversity as assets and a source of resilience. This work also includes assessing
the potential role of discrimination on health and well-being, and understanding the
interactions between the service provider and cli ent’s cultural histories. For
example, is the cultural history relatively neutral or does it resonate with a history of
colonization? All of this may affect the process of cultural sur vival, particularly for
clients who are multiply marginalized. An awareness of culturally
Chapter 3 Diversity and Equity Competencies in Clinical Practice
59

specific interventions and strategies and the capacity to negotiate between

conventional and culture-related definitions of problems and solutions are further
assets in providing equitable care.
This overview of diversity and equity in clinical care aims to build on existing
clin ical competencies by providing (or refreshing) another set of skills to add to
your clinical toolkit to achieve quality care. The practice of “doing diversity” builds
on and integrates with core practice norms, such as client-centred care, self-
reflective practice and the basic goal of providing excellent care, but also requires
specific knowledge and skills. We have explored the linkages and fruitful overlap
between the concepts of diversity, health equity and clinical cultural competence;
diversity as descriptive of unequal power and social location; clinical cultural
competence focused on capacities and skills applied to practice; and health equity
with the aim of measuring and mitigating avoidable health disparities. If our
objective is to achieve respectful, effective, culturally competent and equitable
care, we need to engage with each of these paradigms at the individual, program,
agency and health systems levels.

Practice Tips

• Critically reflect on your own personal and cultural values, norms

and biases, as well as concepts of health and illness and the health
system. • Be aware of social location, power and privilege and
commit to mitigating their impact in service delivery.
• Assess the potential role of discrimination on health and well-being.
• Learn about specific cultural norms and the historic and socio-
political realities affecting the culture or community as both risk and
protective factors.
• Engage the specific meaning of addiction issues and recovery for
each cli ent with a critical, not prescriptive, engagement with
culture and diversity information.
• Navigate the interactions between the service provider and client’s
cul tural and diversity histories.
• Review existing research (population health, public health,
advocacy and epidemiological).
• Engage with diverse communities and community-based agencies
or coalitions.
• Conduct an equity asset audit of your team program or agency and
develop a strategy and action plan.
• Listen to your clients, and look for the signs they give you that
suggest they feel heard and understood.
60 Fundamentals of Addiction: A Practical Guide for Counsellors

Resources
Publications
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Health and Addiction with Ethnoracial/Ethnocultural Communities. Toronto:
Centre for Addiction and Mental Health.
Braverman, P. (2006). Health disparities and health equity: Concepts and
measurement. Annual Review of Public Health, 27, 167–194.
Carpenter-Song, E., Schwallie, M. & Longhofer, J. (2007). Cultural competence
reexam ined: Critique and directions for the future. Psychiatric Services, 58, 1362–
1365. Leininger, M. (1996). Transcultural Nursing: Concepts, Theories and Practice
(2nd ed.). Hillard, OH: McGraw-Hill.
Mikkonen, J. & Raphael, D. (2010). Social Determinants of Health: The Canadian
Facts. Toronto: York University School of Health Policy and Management.
Patychuk, D. & Seskar-Hencic, D. (2008). First Steps to Equity: Ideas and
Strategies for Health Equity in Ontario 2008–2010. Ontario Public Health
Association.
Registered Nurses’ Association of Ontario. (2007). Embracing Cultural Diversity in
Health Care: Developing Cultural Competence. Healthy Work Environments
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developing-cultural-competence
Sen, G., Östlin, P. & George, A. (2008). Unequal, Unfair, Ineffective and Inefficient.
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Srivastava, R. (2008). The ABC (and DE) of cultural competence in clinical care.
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Internet
Centre for Addiction and Mental Health Knowledge Exchange portal—
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http://knowledgex.camh.net/policy_health/mhpromotion/culture_counts/
Pages/ culture_counts_ethno_resources.aspx#competence
Diversity Rx (U.S.)
http://diversityrx.org
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The Hospital for Sick Children)
www.sickkids.ca/culturalcompetence/journey-to-cultural-competence-film/
Journey to-Cultural-Competence-Film.html
National Center for Cultural Competence (U.S.)
http://nccc.georgetown.edu
Chapter 3 Diversity and Equity Competencies in Clinical Practice
61

Statistics Canada Health Profile

www12.statcan.gc.ca/health-sante/82-228/index.cfm
Toronto Community Health Profiles
www.torontohealthprofiles.ca/index.php

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