Toronto mayor Rob Ford’s admission of smoking crack cocaine and drinking has been something of a goldmine for comics and political commentators. The Star newspaper published an online article on what treatment would look like for Ford if he were admitted to a residential addiction facility. The article showcased typical methods of treatment we see in Hollywood portrayals, such as in the movies Clean and Sober or 28 Days. The Minnesota Model is also the main treatment model in the US, with estimates of more than 90 percent of facilities using a similar version.
According to the article, addicts have lost control, are in denial of their addiction, cannot trust their own thinking because they are delusional, are immature, and are extremely selfish. The solution to this problem is to enter treatment, since the addict cannot recover without professional help. The article continues to suggest that since they are out of control and in denial, health care professionals must take control of them. In treatment, the addict must be “serious” about their recovery.
Assumptions About Recovery
There are some questionable assumptions about the treatment described in the article. The Star’s description of treatment contradicts much of what is taught in counselling graduate schools. With its scholarly examinations of theories, practices, and systematic training in counselling ethics. Much of the article seems to fly in the face of modern research on addictions and recovery.
Articles such as this give the impression that addicts are defective. The idea that addicts are immature is a curious one. Some psychologists, such as Abraham Maslow, claim few people achieve emotional maturity. Pointing this out for an addict does not seem to be very revealing. In fact, scholarly research on therapists who judge clients as emotionally immature has shown that this judgment says more about the therapist than the client.
Granted, the author is not a psychologist, but it is interesting that The Star would interpret this version of treatment as an accurate description of how addiction psychologists and counsellors make sense of addiction.
We suggest another form of treatment that the mayor (or anyone) could participate in; one that is steeped in science and ethics. It does not believe that someone suffering from addiction is defective or incapable of making healthy decisions. It does not view them as immature or delusional. Rather, it focuses on helping clients find a new way to make sense of themselves, their world, and their place in the world. It focuses on taking control of their lives, accepting strengths and limitations, and acting according to what is authentically important to them.
Rob Ford is a Complex, Whole Person
The Star article does not present Ford as a human being, with all the complexities and ambiguities of human beings. Rather, because he may have an addiction, the article reduces Ford to an “addict.” To be labelled an addict is to be seen almost as a stereotype. By virtue of having an addiction, the addict has specific personality traits (e.g. “monumental selfishness”) and uses specific psychological defence mechanisms (e.g. denial).
The scientific origins of these simplified perceptions are in the work of Harry Tiebout, a Connecticut psychiatrist trained in Freud’s psychology, who was a “side-line observer” of AA since its inception in 1939. In 1944, Tiebout assessed the character of the alcoholic in active addiction. “The so-called typical alcoholic is a narcissistic egocentric core, dominated by feelings of omnipotence, intent on maintaining at all costs its inner integrity”. Tiebout later described the ego factors as a sense of omnipotence, inability to deal with frustration, and the tendency to do everything quickly.
What is remarkable is that Tiebout’s work is still publicized in some treatment facilities. However, decades of research in addictions and therapy have given us a different picture. For example, it is now clear that the personalities of addicts are as various as the wide mix of society. We now know that the most successful therapies see the client as a unique, complex human being.
Rob Ford is the Author of His Life
In all healthcare, “codes of ethics” is a principle known as autonomy. Therapists are bound by their ethics code to promote the client’s taking responsibility for his or her life. According to The Star article, Ford would be “told he has to fly right or be kicked out.” This taking control of the client contradicts the principle of autonomy.
In fact, telling a client what to do suggests the therapist actually knows what is best. This is a rather arrogant assumption in psychotherapy. Indeed, the vast research on therapists makes clear that therapists don’t have the answers for other adults. Of course, those who believe they know best for the client will argue that addicts are special; they are not like other human beings. However, there is nothing in addiction research that confirms this.
Professional ethics and healthcare systems assume the client is the author of his or her life. It is the individual’s job to make decisions for themself. More and more, the public is learning that they are in charge of their health and their lives.
Rob Ford Has a Right to Informed Consent
All health care codes of ethics stress the principle of informed consent. Informed consent means health care providers must help clients understand the treatment, the risks, and the benefits. This is not a one-time event. Informed consent is always ongoing and the information has to be presented to the person in a way that the person can understand it.
It is clear, then, it would be unethical for a treatment professional to simply impose therapy on a person without helping him or her to understand the scientific basis, success rates, the benefits, and so on of that therapeutic approach. Simply telling a client with an addiction problem that “you are in denial” or “you are emotionally immature” is hardly realistic given all the different theories and practices in addiction psychology.
Once the client understands there are different treatment approaches available, then he or she can make an informed decision on whether to continue treatment. The provider would, then, be bound to help the client find a therapy that resonates with him or her. To provide informed consent is to respect the principle that the client is the author of their life.
Therapists Work with Rob Ford
According to motivational psychology, imposing a way of thinking onto clients is a very weak way of changing behaviours. If externally imposed ideas are going to work, clients must absorb them.
Psychologists have described what happens when individuals do not accept such frameworks. If the external motivation and goal are not completely integrated into the individual’s understanding then they have limited effect. When externally regulated, people are likely only to act when prompted, rewarded, or controlled. They do not ‘own’ their behaviours or values they enact. Furthermore, others who have only partially absorbed the external motives (“introjected regulation”) act to avoid shame and guilt or, oppositely, to feel self-glorification or pride.
Professionally trained therapists work with clients to help them find a new way of living. One of the tactics is for the therapist to get curious. If the client says that he wants to continue drinking after treatment, the therapist does not tell him “that’s dumb.” Rather, the therapist gets curious about what the appeal of drinking retains for the client. Perhaps the client thinks that if he does not drink then he is less of a man or defective. He is afraid that life without alcohol will be too boring. These issues of masculinity, defectiveness, and boredom are the “stuff” of therapy.
Therapists See Constant Confrontation as Malpractice
The Star article said that if Ford entered treatment, he “will be called to account by others who know the game.” Confrontation as an acceptable counselling style is remarkably prevalent in addictions treatment. Psychologists, Miller and White, reviewed the scholarly research on confrontational counselling and concluded this did not work.
This confrontational approach could be considered malpractice. It is, of course, important for therapists to confront clients. However, this is an occasional technique, certainly not a style of counselling.
Generally, those who practice confrontational counselling argue that addicts are in denial. Therefore, the therapist must be confrontational to break through this denial. The whole idea of “denial” is a curious one. SCHC research has shown that those suffering from addiction have a remarkably weak sense of self. Any “denial” of addiction is a simplistic, and misleading, description of a pervasive dynamic: a weak sense of who they are and how they fit in the world around them.
Treatment at a Human Level
Therapy is not the mental equivalent of having a root canal. The addict must first be beaten down, which the article points out is unpleasant. This old idea is so pervasive in residential addiction treatment, one wonders if it is causing problems.
Estimates are that 80% of those suffering from addiction refuse to seek help. Would more people choose therapy if they knew they would not be shamed, confronted, or told what to think and do? Would they be more willing to enter treatment if therapists respected what they thought?
Similarly, many rehab centers have a high discharge rate. These discharges typically occur because the client did not “follow instruction”. Since one of the scientific markers for successful recovery is completing a program, it seems odd that clients would be discharged for not following rules. Which, frankly, often have little or nothing to do with therapy.
One wonders what our success rates would be if treatment providers (1) saw the client as the author of their life, (2) treated a whole and complex human being, not an addict or an addiction, (3) worked with the client rather than imposing a framework on the client, and (4) provided space for the client to feel free to be themself, with no need to distort or deny the experience.