What is Addiction Counseling?

At this stage of my career, it seems to me that “Addiction Counseling” is one thing made from the following four essential ingredients:

listening with the “third ear”;
those unique competencies and skills that are particular to the professional addiction counselor;
the competencies and skills particular to the recovery coach; and finally,
the qualities of a recovery carrier.

And I’m also of the opinion that for an addiction counselor to be maximally effective, all 4 must be developed separately. (The related matter of career-long clinical supervision I will not be able to address in this work).

To help convey what I have in mind about this matter of addiction counseling as a functional unity derived from four ingredients, I’ll represent my thinking with the diagram below. Then I’ll provide a description of each of the four components.

Clarity From a Learning Circle

Over the last several months I’ve been working with a small group of addiction counselors in what I’ve called a “Learning Circle”. Our weekly gathering is supplementary to, and not for the purpose of, formal clinical supervision. The attendees are significantly earlier in their addiction counseling career than me. My sustained effort of leading and facilitating this learning circle has been very refreshing. And it has pushed me in the direction of identifying, clarifying, simplifying, and communicating what is essential. I’ve gained a lot from the effort.

In this effort, I’ve been pondering what topics to share, and in what order. And I’ve been pondering this consistently over months while we’ve been meeting. One of the topics I’ve identified I’ve formed as a question: “What is an addiction counselor?”

If I wanted to try to locate the answer or parts of the answer for the purpose of discussion in the learning circle, where should I look? Some standard places to look include:

The SAMHSA Technical Assistance Publication number 21 (TAP 21) titled “Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice”¹ ,
The IC&RC’s 12 addiction counselor core functions², and
The 8 counselor skill groups from NAADAC and the NCC AP³.

Taken together, these might be thought of as collectively comprising the bottom line essence of what an addiction counselor does – the standards of minimal competency and skill for addiction counseling as a professional discipline.

But in considering this, I’ve realized I have a different way – my own way – of identifying and representing the essence of addiction counseling. And I’ve pictured my thinking in the diagram above.

Below, I’ll un-pack the diagram from an introductory standpoint.

Four Ingredients of an Addiction Counselor

Ingredient one: “Recovery Carrier”

It seems to me that the inner-most essence of an addiction counselor is that of a recovery carrier⁴. (Readers should note that the phrase “recovery carrier” is a term with a particular meaning. It cannot be understood by merely grasping the simple English words found in its name; to understand the term, one must read the original paper that describes the particular concept).

“Recovery Carrier” is a particular and unteachable quality of a person. In my opinion, that particular quality (its presence and nature) sets a ceiling or upper limit on the effectiveness of an addiction counselor. In that way its presence could be considered a prerequisite of effective addiction counseling. The original paper describing the recovery carrier notes that being “in recovery” does not on its own make one a recovery carrier, and that not being “in recovery” does not on its own preclude one from being a recovery carrier.

Ingredient two: Listening with the “third ear” It seems to me that there is an outermost function of an addiction counselor that I would describe as “listening at depth”. In my thinking “listening” also includes other modes of perception beyond literal hearing, such as “seeing” and so forth.

Why do I consider this capacity of listening with the third ear an outermost function? Because it is a kind of outwardly focused environmental scanning that is both actively seeking and passively gathering.

But to me, beyond outward scanning, “listening with the third ear” also includes a kind of deep or inward listening – listening in the inward direction to one’s own inner resources.

Combined, this evokes apprehending of whatever is detected. This apprehending can be thought of as roughly equivalent to understanding or interpreting, and may emanate from any combination of deductive reasoning, inductive reasoning, and seemingly spontaneous or emerging intuition.

Listening with the “Third Ear”⁵, then, is a capacity to listen attentively, calmly, and at length if necessary. But beyond that, it’s the capacity to listen at the level of understanding and at the level of the covert. It is not merely a hearing of the overt. It includes the capacity to listen with one’s own unconscious, and to notice one’s own emerging understanding or countertransference – as information – rather than something to be stifled.

This capacity is best grown and developed intentionally in its general ability, parameters, and content. In my experience, this type of listening is developed over time. It cannot be “installed” by education. And it doesn’t come about or improve just by experience alone – it must be purposefully practiced, sharpened, and improved.

Can we hear and identify what is happening that the patient themselves is not even entirely aware of?⁶
Can we hear and identify what the patient does not themselves clearly understand?
How are we to “throw flour on the invisible man”⁷ if we cannot detect its presence?
Are we developing the capacity for high-quality listening that includes the domains of the obvious and the covert – of both self and others?

Many clinical disciplines function with this capacity of listening followed by understanding. And the content I have presented so far about this capacity I have borrowed from psychodynamic psychotherapy. But addiction counseling performs this function while including addiction counseling and recovery management competencies in the material being considered.

The addiction counselor, then, must have this capacity functioning with regard to two major content areas and the factors within them: psychology in general, and addiction-related matters specifically.

With regard to psychology, the addiction counselor benefits from attunement⁸ to psychodynamic matters that might be just outside of the awareness of the patient.
Concerning addiction-related matters, the addiction counselor benefits from attunement that produces the capacity to hear the illness, the change process, the patient’s movement (progress, stuckness, regression), and the patient’s individualized recovery (its nature, progress, regress, and stasis).

Moreover, the addiction counselor’s understanding benefits from noticing and hearing the object relations⁹ between and among these factors and the person of the patient.

Ingredients three and four: Extended from the space held by the recovery carrier and third-ear listening functions are the activities of addiction counseling and of recovery coaching. Each of these two activities have their own base of specific knowledge and skill. I’ll briefly outline them below.

Addiction counseling is a constantly evolving and specialized clinical discipline^10-12. Considering the very wide array of clinical presenting pictures and individual patient’s particular life circumstances, a variety of knowledge and skill areas within addiction counseling are potentially quite valuable. Some that come to mind include:

Symptoms, signs and associated features of addiction progression and recovery advancement (e.g. Jellinek¹³; DSM¹⁴)
Stages of progress from the illness into and through early recovery, and later into and through extended recovery (e.g. Gorski¹⁵)
Classical conditioning related to addiction etiology and progression (e.g. Siegel¹⁶)
Addictive thinking (e.g. Twerski¹⁷; McCauley^18,19)
Chemically dependent family system (e.g. Brown²⁰; Myers²¹)
Relapse prevention therapy seated in CBT (e.g. Marlatt²²; Kadden²³)
Contingency management (e.g. Petry²⁴)
Trauma as co-occurring (e.g. Najavits²⁵)
Stimulant-specific method (e.g. Rawson²⁶)
Motivational Enhancement Therapy (MET)
Motivational Interviewing (MI)
Community Reinforcement Approach (CRA²⁷)
Twelve-Step Facilitation (TSF²⁸)
Acceptance and Commitment Therapy (ACT²⁹)
Young adult models^30,31 and “maturing out”³²
Culture as treatment³³
Medication maintenance and compatibility with recovery (e.g. White & Coon³⁴).

Recovery coaching

While I was working at Fayette Companies/Human Service Center (HSC) in Peoria, Illinois, the Behavioral Health Recovery Management Project (BHRM) was begun and operated. The BHRM project produced a wide variety of innovated materials including principles, practice guidelines, and specific techniques. The BHRM Statement of Principles is a worthwhile read.

The big-picture theory and related practice methods eventually became known as “Recovery Oriented Systems of Care” (ROSC)³⁵. The person-level smaller picture methods eventually became known as “Recovery Management” (RM)³⁶. I was on the steering committee that oversaw and led our agency’s internal implementation of the BHRM project’s total content for the entire 10 year lifespan of the project (roughly 1998-2007).

“Recovery Coaching” was invented within and implemented as part of the BHRM project. As originally developed, recovery coaching was entirely different and separate from professional addiction counseling. It was conceived as pertaining to a very particular kind of staff and staff skills – based on and seated in experiential knowledge acquired from the perspective of the person served. That kind of knowledge differs in focus and source from knowledge that is academic and professional. The original recovery coach manual³⁷ from our agency is publicly available, and a potent resource.

One metaphor we often used to educate our employees on the concept of coaching (as it applied to recovery coaching) was that of someone learning fly fishing. That type of learning requires a coach in close physical proximity to the learner. An additional type of coach function we referred to that carried an important distinction was that of the soccer coach (more physically distant, and attending from the sideline). That kind of coaching can call in suggestions, and also be accessed as a resource. Regardless, one should keep clearly in mind that both kinds of coaches trade in the “experience-near” (Kohut) type of understanding, and do not rely on merely academic or expert-type of top-down knowledge. We had a staff of recovery coaches that worked with the patient in both styles of coaching, as needed. We also made very early use of an “On-Star” type of coach function with access via a free flip-phone given to the patient for that very purpose.

Originally, the recovery coach function was kept separate from the counselor function. We made sure the two different functions of coach and counselor resided in different kinds of employees – one or the other. To me, at this stage in my career, it seems that the addiction counselor is best equipped if they are also able to function as a recovery coach at times.

(And yet, I do think I would continue to preserve a recovery coach function that is also within some people who function as recovery coach specialists and are not professional addiction counselors).

Below, I provide an alternative diagram that attempts to picture the object relations among and between these 4 ingredients of addiction counseling. Perhaps considering these four ingredients from the perspective shown in the diagram will be helpful.

In my opinion, the value of such a concrete representation as the diagram above is revealed by the presence of one actual patient, in our office, as a person wanting help. Listening, coaching, counseling, and letting our presence emanate: these areas of function most definitely inter-relate. And that interplay of functions, as object relations interacting with our self as a person and with the patient as a person – to me – comprises the essence of addiction counseling.

Addiction counseling as a specific discipline

Lastly, I ask, “Should addiction counseling continue to exist as a specific discipline? Is its continued existence even necessary?”

In my experience, the person presenting in a clinical setting or service with a complex and severe mid to later-stage addiction illness has some particular needs that can be recognized and met by a competent and skilled addiction counselor. And some of those needs are not likely to be recognized and met without addiction counselor competency and skills being present. With such patients, in my experience, the broad awareness of mental health problems and general counseling methods found in other clinical disciplines are not sufficient by themselves.

If it were up to me, I would continue to preserve and develop the knowledge, wisdom, understanding, and techniques of addiction counseling.

And I would continue to hold and develop addiction counseling as a specialty.

I would not want to dilute or lose addiction counseling’s particular nature and methods within an alternative broader arena of general counseling for people with a variety of needs in behavioral health and primary health.

Rather, I would want us to pursue the best collection of addiction counseling’s specific capacities, functions, and techniques over time – leading to an even more synergistic and robust set of specialty knowledge and skills – for the sake of those we serve.

References

¹Center for Substance Abuse Treatment. (2006). Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice. Technical Assistance Publication (TAP) Series 21. HHS Publication No. (SMA) 15-4171. Rockville, MD: Substance Abuse and Mental Health Services Administration.

²International Certification and Reciprocity Consortium (IC&RC). IC&RC – About Us (internationalcredentialing.org)

³NAADAC and the NCC AP. About the NCC AP (naadac.org)

⁴White, W. (2012). Microsoft Word – 2012 Recovery Carriers.docx (chestnut.org)

⁵Reik, T. (1948). Listening With the Third Ear: The inner experience of a psychoanalyst. Farrar, Straus & Co.

⁶Luft, J. & Ingham, H. (1955). The Johari Window, a Graphic Model of Interpersonal Awareness. Proceedings of the Western Training Laboratory in Group Development. Los Angeles: UCLA.

⁷Coon, B. (2021). “Throw Flour On the Invisible Man”: Toward locating recovery function and assessing recovery quality (recoveryreview.blog)

⁸Rowe, C. Jr. & Mac Issac, D. (1989). Empathic Attunement: The “Technique” of Psychoanalytic Self Psychology. Jason Aronson, Inc.

⁹Hamilton, N. G. (1988). Self and Others: Object relations theory in practice. Jason Aronson.

¹⁰White, W. (2004). The Historical Essence of Addiction Counseling (chestnut.org)

¹¹White, W. (2007). Counselor Magazine’s Addiction Professional’s Reference Guide. Health Communications, Inc.: Deerfield Beach, FL.

¹²White, W. (2014). The History of Addiction Counseling in the United States: Promoting Personal, Family, and Community Recovery. NAADAC.

¹³Jellinek, E.M. (1952). Phases of Alcohol Addiction. Quarterly Journal of Studies on Alcohol. 13(4): 673–684.

¹⁴American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

¹⁵Gorski, T. T. & Miller, M. (1986). Staying Sober: A guide for relapse prevention. Independence Press.

¹⁶Siegel, S., & Ramos, B. M. C. (2002). Applying Laboratory Research: Drug anticipation and the treatment of drug addiction. Experimental and Clinical Psychopharmacology. 10(3): 162–183. https://doi.org/10.1037/1064-1297.10.3.162

¹⁷Twerski, A. J. (1997). Addictive Thinking: Understanding self-deception. Hazelden Publishing.

¹⁸McCauley, K. (2009). Pleasure Unwoven: A personal journey about addiction. Institute for Addiction Study.

¹⁹McCauley, K. (2016). Memo to Self: Protecting sobriety with the science of safety. Institute for Addiction Study.

²⁰Brown, S. & Lewis, V. (1999). The Alcoholic Family in Recovery : A Developmental Model. Guilford Press.

²¹Myers, R. J. & Wolfe, B. L. (2003). Get Your Loved One Sober: Alternatives to Nagging, Pleading and Threatening. Hazelden Publishing.

²²Marlatt, G. A., Parks, G. A. & Witkiewitz, K. (2002). Clinical Guidelines for Implementing Relapse Prevention Therapy: A guideline developed for the Behavioral Health Recovery Management Project. Clinical Guidelines for Implementing Relapse Prevention Therapy (recoveryreview.blog)

²³Kadden, R. M. (2002). Cognitive-Behavioral Therapy for Substance Dependence: Coping skills training. Cognitive-Behavior Therapy for Substance Dependence: Coping Skills Training (recoveryreview.blog)

²⁴Petry, N. (circa 2003). A Clinician’s Guide for Implementing Contingency Management Programs: A guideline developed for the Behavioral Health Recovery Management Project. A Clinician’s Guide for Implementing Contingency Management Programs (recoveryreview.blog)

²⁵Najavits, L. M. (circa 2003). Implementing Seeking Safety therapy for PTSD and substance abuse: Clinical Guidelines. Implementing Seeking Safety therapy for PTSD and substance abuse: Clinical Guidelines (recoveryreview.blog)

²⁶Rawson, R. A. & McCann, M. J. (circa 2006). The Matrix Model of Intensive Outpatient Treatment: A guideline developed for the Behavioral Health Recovery Management Project. The Matrix Model of Intensive Outpatient Treatment (recoveryreview.blog)

²⁷Myers, R. J. & Squires, D. D. (circa 2003). The Community Reinforcement Approach: A guideline developed for the Behavioral Health Recovery Management Project. The Community Reinforcement Approach (recoveryreview.blog)

²⁸Nowinski, J., Baker, S. & Carroll, K. (1995 reprint). Twelve Step Facilitation Therapy Manual: A Clinical Research Guide for Therapists Treating Individuals With Alcohol Abuse and Dependence. Project MATCH Monograph Series, Volume 1. NIAAA.

²⁹Bach, P. A., & Moran, D. J. (2008). ACT in practice: Case conceptualization in acceptance and commitment therapy. New Harbinger Publications.

³⁰Coon, B. (Mar/Apr 2023). Reconstructing Diagnostic and Therapeutic Methods for Younger Adults with Substance Use Disorders. Counselor.

³¹Enos, G. A. November 21, 2016. A Young-Adult Treatment Approach With Visual Appeal. Addiction Professional. A young-adult treatment approach with visual appeal (hmpgloballearningnetwork.com)

³²Dunkel, C. S, Kelts, D. & Coon, B. (2006). Possible Selves As Mechanisms of Change in Therapy. In Dunkel C. S. & Kerpelman, J. (Eds.), Possible Selves: Theory, Research and Application. Nova Science Publishers.

³³Brady M. (1995). Culture In Treatment, Culture As Treatment. A critical appraisal of developments in addictions programs for indigenous North Americans and Australians. Social Science and Medicine. 41(11):1487-98. doi: 10.1016/0277-9536(95)00055-c.

³⁴White, W. & Coon, B. 2003-Methadone-and-Anti-medication-Bias.pdf (chestnut.org)

³⁵Evans, A.C. & White, W.L. (2013) “Recovery-oriented systems of care”: Reflections on the meaning of a widely used phrase. Posted at multiple recovery advocacy web sites and at www.williamwhitepapers.com 2013-ROSC-Definition-Elaboration.pdf (chestnut.org)

³⁶Kelly, J. F. & White, W. L. (Eds.). (2011). Addiction Recovery Management: Theory, research, and practice. Humana Press/Springer Nature.

³⁷Loveland, D. & Boyle, M. (2005). Manual for Recovery Coaching and Personal Recovery Plan Development (recoveryreview.blog)

Supplemental Reading

Center for Substance Abuse Treatment. (2007). Competencies for Substance Abuse Treatment Clinical Supervisors. Technical Assistance Publication (TAP) Series 21-A. HHS Publication No. (SMA) 12-4243. Rockville, MD: Substance Abuse and Mental Health Services Administration.

Coon, B. (2022). Comments on the Task of Interpreting (recoveryreview.blog)

Acknowledgement

Thanks to Jason Schwartz for his comments on a previous version of this writing.