Art as a Reflection on Counseling: What Does the Client See?

The attached is a quick snapshot of a piece of art I discovered when cleaning out my home office. It is somewhat difficult to tell what you are looking at unless you look closely…and perhaps with a magnifying glass…but if ever in Philly, you are invited to stop by, have some tea, and take a look, “up close and personal.” 

About 20-some-years ago I did an alcohol and other drug assessment with a young man who was mandated following a drug violation…marijuana. We did the assessment and although he was not a candidate for in-patient “drug treatment,” he was well on his way to developing a substance use disorder.


At the end of the assessment, I was looking for some way to make its results more personally meaningful for him. Because he was an artist and a huge fan of graphic novels, I asked him to prepare a review our assessment graphically: The artwork below was his rendition of the outcome of that meeting.

Essentially he storyboarded his insights regarding his drug use, projecting into the future where it might take him if he chose to ignore the results of our assessment. Although I suspect he took some artistic license in producing this piece—I did not see a violent death to be very likely in his future even if his continued use did progress to addiction—it nonetheless tells a cogent story and presents a somewhat accurate picture of the progression of a SUD, at least in Philly. More importantly, it was his interpretation of where his use might lead lest he make changes.

In any event, I thought I would share this as a way of suggesting that individuals can be invited to react to counseling in ways other than just words. What do you think?


Dr. Robert

Giving Away Beer to Attract Younger Customers: Crisis in the Making or Desperate Attempt to Counter a Shrinking Market?

AA, Spirituality, Religion, and Professional Counseling: Part II

As mentioned in my last post, AA (and other 12-step fellowships) neither advocate for nor against any issues, including whether those with symptoms of substance use disorders should become involved with AA. The issue of primacy in this discussion is how do we, practitioners of counseling, interact with AA and, more to the point, the role it plays in the care plans we negotiate with individuals involved with us in counseling.

As with many issues that surface in counseling, counselors are taught to explore all options with clients and eschew pushing a personal agenda. This does not mean that we do not have professional opinions about what works best or better than other things, but it does mean that we need to assess the client’s wishes and attempt to find a course of treatment that is appropriate in our professional opinion while at the same time consistent with the individuals wishes.

True, AA is not for everyone. That said, it seems to work well for many--and whether this means initially finding sobriety or pursuing recovery once  "dry"--this is an issue that the practitioner should consider when determining: (1) If a referral should be discussed and, more to the point, (2) when that discussion should take place in the counseling relationship. Because of the success so many recovering people attribute to 12-step programs, contemporary counselors cannot not consider such programs as a potential adjunct to professional counseling. This does not mean that “all” clients should be referred, but neither does it mean that none should be referred. It is part of what professional counselors do to determine: (1) What will work best, (2) for this individual, (3) at this particular time, (4) to best address this or her needs.


If counseling practice has changed at all over the years it is to have moved away from treating the diagnosis a client has and focus on providing service to the individual who presents seeking care for his or her needs. True, one’s diagnosis will inform the course of this treatment, but as I mentioned in my earlier post on this topic, “there are many paths to the same destination.” 


So, it seems to me that the issue is not “if” AA is appropriate, i.e., is it evidence-based treatment? Is it too religious/not religious enough, etc.? Rather the issue is how and when do I, as a professional counselor, address this issue with individuals for whom a diagnosis of a substance use disorder is appropriate. For John Jones the decision may be to not discuss this now, but perhaps later. For Mary Brown it may be to refer her immediately, and for little Johnny Middleschool, it may be to not discuss this option at all unless Johnny bring it up.

The second issue of importance in this discussion seems to be mandating individuals to attend meetings. I have to agree that mandating treatment of any sort is questionable in its effectiveness. Like the old saying goes, “Never teach a pig to sing; it annoys the pig and frustrates the teacher.” That said, there is something to be said for mandating attending “X” meetings. This is not mandated treatment as much as mandated window shopping. Any first-year psych major exposed to Bandura’s Social Learning Theory quickly can appreciate the significance of vicarious learning, which is exactly what happens when individuals attend meetings, even when mandated. For counselors to rail against the criminal justice system for its infringement on the civil rights of individuals mandated by the court to attend “X” meetings may be missing the point. 


AA and other 12-step fellowships are not treatment. First of all AA will never even discuss this as it is a violation of its tradition to remain silent on issues of politics, religion, etc. So mandating attendance to a specific number of meetings may be a hassle for the individual referred, may be perceived as having been made to “go to church,” or may simply be viewed as a waste of time, but we forget Bandura’s findings resulting from all that research in the 70s...you know what you learn and learn what you are taught...and life is a most effective teacher. And as with so many things, something new is only learned when something new is presented in such a way as to allow the observer to recognize that “the new” costs less and has fewer hassles than what was previously believed.


In my counseling career, I have told individuals, both those who voluntarily attend and those mandated to do so, to: (1) Go to a larger, open meeting, (2) arrive as the meeting is about to start, (3) sit in the back and do not say anything unless you want to, (4) leave when the meeting is over, and (5) do not just listen to the speaker but watch the other people at the meeting...what are they doing? Are they complaining or simply talking? Are they laughing or sitting sullen with their arms folded on their chest? Are they smiling or frowning? I suggest that we discuss what was seen and heard, but not just what the speaker or chair had to say, but what were the dynamics of the whole meeting they attended.


In summary, our issue as professional counselors is to determine what is best for the individuals with whom we work, but to do so in concert with their input. This means that what some may consider as controversial options, such as attending mutual aid groups as an adjunct to professional counseling, need to be considered and evaluated for appropriateness not based on their merits—they all have merits in their own right and these are clear for those who are actively involved—but based on what the individual with whom we are working wants to accomplish.

What do you think?

Dr. Robert

AA, Spirituality, Religion, and Professional Counseling: Part I

This is a topic of  importance and one that is appropriate for consideration at the start of a new academic year where the next generation of counselors—especially addiction counselors—will begin their education and training. That said, I suspect that commenting on this topic may result in a post more the length of an essay than a concise blog entry. I mention this so that readers can exercise the option to use the delete key—if you will pardon the pun—as this is why a Higher Power placed it on the keyboard…Bill Gates? Steve Job? J

A risk, I suspect, in discussing this topic is that it could be like trying to explain health care reform to your 90-year-old parents who consider Fox News and its pundits the only credible source of information on life in these United States; so be it…I love my parents dearly irrespective of their news retrieval habits and political bent.

So, concerning the question of the religiosity in 12-step recovery programs, my experience over the past 36 years as a professional counselor specializing in substance use disorders is that most of my colleagues who have voiced this concern have attended relatively few open 12-step meetings and many of those they may have attended were often the same meeting, meaning, a “particular” group on a particular day and time, attended by specific individuals where one or more indeed placed a distinctly religious spin on the “suggested steps” for recovery. As the old adage suggests, “You never get a 2^nd chance to make a 1^st impression.” If my understanding of 12-step programs had been influenced by such first-hand contact with 12-step programs or my understanding had come exclusively from what others have told me—addicted individuals who eschewed 12-step programs and/or colleagues who voiced concerns—then I too would risk engaging in what our field refers to as “confirmation bias” or the tendency to discount information inconsistent with a held belief while pointing to isolated examples of my belief as evidence of its veracity. Personally, I have been to hundreds of AA meetings in 36 years and have a larger sample on which to base my points in this post.

I do not doubt that some, both in the “addiction treatment industry” and in personal recovery, see “spirituality” and “religion” as all but synonymous, but this is neither universal in its acceptance in the counseling field nor supported in the literature of AA—I am not as familiar with the literature of NA, OA, or the other 12-step groups, so I will not make a blanket statement regarding “all” 12-step-oriented literature. I address this issue of the difference between spirituality and religion in an article I published some years ago (Chapman, R. J. [1996].  Spirituality in the treatment of alcoholism: A worldview approach.  Counseling and values, 41[411], 39-50 - see http://www.robertchapman.net/essays/spirit.pdf for a PDF of the article). Likewise, in my classes I use an unpublished essay I wrote that provides a “counselor’s perspective” on each of the 12-steps in AA when addressing 12-step programs in my Intro to Addictions course. As this is unpublished, I invite requests (Chapman.phd@gmail.com) for copies by those who may be interested.

The question regarding involving individuals in treatment for a substance use disorder in mutual aid groups such as AA needs to be based on more issues than the perceived religiosity of such programs by the counselor—either the counselor who refuses to refer or the counselor who insists on it. There are numerous reasons why a referral should be made as an adjunct to professional treatment even if the practitioner believes that there is too much God in 12-step programs—by the way, AA suggests that if the “G-word” is too upsetting, view it as an acronym – Good Orderly Direction. In an article entitled, Mutual support helps sustain treatment gains (see http://findings.org.uk/docs/nug_4_3.pdf), one study found that the irrespective of the philosophical tenets of mutual aid or self-help groups, the social support and networking alone is reason to consider such programs as an adjunct to professional treatment. In a conceptual article entitled, Self help: don't leave it to the patients (click title to read) “Keith Humphreys and colleagues report on a workgroup of US experts on substance abuse self-help organizations. Main conclusion: self-help groups are too valuable to leave to chance. They should be actively promoted and facilitated by treatment services and policymakers” (http://findings.org.uk).

My experience has been that many colleagues who have voiced concerns about the religiosity of 12-step programs have focused on this issue to the exclusion of other potential benefits that such referrals may proffer for individuals in early recovery. The concern voiced to justify avoiding such programs when developing service plans for individuals in treatment is that involvement in AA is to trade one addiction for another. Although most recovering people I have met have viewed their involvement in a 12-step program as being critical to their sustained recovery, they are quick to point out that one cannot hide in 12-step programs to the exclusion of responsibilities to family, job, or community. As a matter of facts the middle third of the 12-steps is about personal responsibility and obligation in these critical personal areas of one’s life and therefore recovery.

Another justification for avoiding 12-step program referrals espoused by some because of a concern for their perceived religiosity is the language of the 12-step and in AA literature. There is no denying that the language of 12-step literature is, by today’s standards, sexist and speaks of “most” referring to their Higher Power as “God.” This is, perhaps, one of the more legitimate arguments concerning this issue. Be that as it may, one needs to realize that this language was written in the late 1930s and 1940s and at a time when these words were the proverbial “coin of the realm.” We need to remember that “words” are but verbal symbols (when spoken), imbued with meaning by those who use them and by those who hear them. To assume a word’s meaning today when written 60+ years ago may not necessarily yield an accurate interpretation of the author(s)’ original intent. Like when my then 14-year old son took me to task for listening to the Drifters singing Under the Boardwalk in the early 90s as we rode in the car listening to the oldies station when they crooned about “making love” under the boardwalk—we had recently discussed my concern regarding the lyrics of the Heavy Metal music to which he listened—the socially constructed meaning of language can change…he heard a song about having sex when in the 1950s, “making love” meant so much more that the physical act of intercourse.

What I have found through the decades is that I can address potential concerns a “client’ may have by: (1) prepping individuals for what they will experience at 12-step meetings, (2) suggesting that “the words” they may hear/read are just that, words, and their meaning as regards change is not religious in nature, and (3) outlining how there is more to a 12-step group and its potential to aid in recovery than “the meetings” or “the steps” or the whatever. It is a package: Available 24/7…Presenting an opportunity to observe others who have learned a skill set that has served them well as regards making difficult changes…Presenting an opportunity to meet individuals who have similar social/cultural/athletic/political/’whatever” interests and yet, still do not use.

I do not agree with everything in the platform of the political party to which I am registered; I do not subscribe to all the teachings of the religion that I practice; I certainly do not agree with my parents and their views on “most things social and all things political,” but I nonetheless find all these to be critical to finding my way through the challenges of my contemporary living.

I have worked with individuals with substance use disorders for too many years to believe that there is anything like “the” way to recovery—as I learned when working on a reservation with Native Americans, “There are many paths to the same destination.” AA, NA, and the other “anonymous” fellowships have worked too well for too many for too long to be dismissed “out of hand” based on a single issue.

In closing, as I pen this post, I find myself thinking about the core ethical principles that Corey & Corey espoused in their ethics text ( Issues and Ethics in the helping professions, 7^th edition,) and that I share in my ethics course with undergraduate behavioral health counseling students: Autonomy, Nonmaleficence, Beneficence, Justice, Fidelity, and Veracity—especially Autonomy or the right for the client to make his or her own decision as to what course to follow ( p. 17 - 19). I realize that those who disagree with my arguments in this post can turn this closing point on me and suggest these are exactly the reasons they do not refer to 12-step programs, but, to paraphrase myself from above, I have seen too many individuals over the years not only get sober in AA, but find a serenity and quality of life that leads me to believe that while it may not be for everyone, it is certainly for many and who am I to decide who those “many” will be for whom AA (or other such fellowships) are a fit. I discuss 12-step programs with all clients; I mandate that all students in my addiction class attend a minimum of 2 meetings and write a critical essay on the experience; I invite members of the Cooperation with the Professional Community committee of AA to speak in my addiction class. My students will make up their own minds about the appropriateness of including 12-step programs in their approach to professional counseling, but this decision is made, hopefully, with first hand information plus my personal attempt to invite that their consideration be based on “the big picture” rather than their propensity towards “confirmation bias.”

 What do you think?