Fundamentals of Addiction A Practical Guide for Counsellors

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 several 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 information 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 contemporary 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 processes 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 inequalities. 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 psychodevelopmental. 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 vulnerabilities. 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 comprehensively 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 compelling 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 communities seek to thrive and flourish beyond the constraints of addiction. If there is more to human beings than even a multi-dimensional, integrative, pluralistic 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 behavioural 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 produces 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 behavioural 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 successful 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 alcohol, 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 characteristic of their problem. Implicit in this model is the concept of addiction as occurring along a continuum. 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 addiction 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—substance abuse and substance dependence—into one category—substance use disorders, or diagnoses that require specification of a particular substance (e.g., cannabis use disorder). 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 occurring 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