A Three Dimensional Approach to Treatment

Overview

My story begins with a conceptual framework integrating multiple concepts into a whole.

Out of this effort I found a synergism. I found that integrating the parts gave me an understanding that was larger than the sum of the parts.  

Addiction is often a flawed treatment method for a disability in thinking.
 

I want to begin by telling you how I came to blend several approaches to therapy into a new framework. What I found is a way to blend relational, cognitive-behavioral and constructionist-developmental techniques. I can only speak for myself as I describe what I have found, so I am just going to tell my story. I hope this helps you understand why I value this approach.

My History

In my childhood I had experiences that taught me to be quite sensitive to the emotions and nuances of those around me. I felt a calling to work with people, but my father insisted that my career should be technical. People who work with technology tend to focus on technology. Most keep their personal selves pretty well hidden. I am a good mimic so when I was asked to train others in technology I focused on the subject matter and ignored the people. The net effect is that I came to value the cognitive approach, even if I did not know it had a name.

Intuitively I knew that the way I related to people was too stiff. So I read books on relationships, expecting that relationships were just another form of technology. Once I found Carl Rogers, however, my world changed. I began to use "active listening" and "unconditional positive regard" and I found that people reacted differently. I then worked diligently on my relational skills.

One person who found my relational skills interesting became my wife. Within the first two weeks of our marriage two of our closest relatives suffered life threatening medical emergencies. The next week we moved from the southern part of the Pacific coast to the northern part of the Atlantic coast and both changed careers. Within two more weeks our only remaining grandparents died. All of this created a tremendous stress on us and my wife needed assistance. We found a psychoanalytic psychiatrist. He explained that professional psychiatry is extremely complex and amateurs should stay home. So I read more books on unconditional love and I started studying Freud and the psychoanalytic approach.

A couple years later a neighbor knocked on our door and asked for help. He needed to get into an addiction recovery program. He trusted us and felt like we were connected. I knew this was because I gave him unconditional positive regard, and I knew he had no one else to turn to. We took his child in to live with us and made arrangements for our neighbor to check into a rehab program. When he completed that program we helped him get into an aftercare program. Whenever he came around I spent time talking with him and we would provide meals and shelter as we could. But he was getting worse. He said that the connection inside the rehab program had better stuff at a lower price than his regular connection. And once he was out he used the aftercare center to meet his regular connection. He died a few months later.

This was the second time that I concluded that unconditional positive regard was not enough. I was also disappointed that the professionals had missed what I thought were obvious signs. So I volunteered to work on a drug and suicide hot line both to help others and to try to learn what I should have done differently. When I asked the experts in this program they told me that addicts were pretty hopeless. The theoretical explanation I got was that addicts have arrested development. The popular theory is that an addict stops their mental growth when they start to use. It seemed to me that the logical thing to do was to find a way to restart their development so I began studying developmental psychology.

As I worked on that hot line I continued to practice my skills in relational therapy. I also began to pick up clues in the conversation that helped me guess at the developmental age of the person I was talking with. I had read Erikson. Now I read Kegan, Piaget and others. And I began to feel like I could speak to the person in an age appropriate way. Some 40-year olds think like they are 18. Some 50-year olds behave like they are still 10. I do not know how accurate my guesses were, but the people who called seemed to appreciate my approach.

A few years later I began teaching college. I still used a cognitive approach to the subject matter. But now I tried to build a nurturing environment using relational skills. And I tried to present the material in ways that were accessible to the range of developmental ages that were present. People saw that I was different and most liked what they saw.

When one of my relatives was faced with a difficult choice the family asked me to work with her. I was already studying marriage and family counseling and agreed to assist as I could. My relative was already working with the professionals on the hospital staff so this was similar to what I did when my wife was seeing a psychiatrist and when my neighbor was on drugs. The professionals would do the work while I provided support. But the patient died.

Once again I felt challenged to change. Our grief also affected my wife and I tried to please her like I had tried to please my father by changing careers. Organizational psychology seemed like a safer way to put my skills to use helping people. But I began feeling torn between what I wanted to do and what I was actually doing. So I let the marriage slip away and I dedicated my life to studying strenuously. After years of effort I found a way to align several theories on organizational psychology into one framework.

Right in the midst of writing about this framework I met someone who ignored my walls and walked into my life. This lovely lady captured my heart and then she needed my help. I used all of my relational skills to be her lifeline. We took classes and went to twelve step meetings where we found supporting relationships and an abundance of cognitive wisdom. We talked about our developmental issues and I found that I had shifted from using developmental concepts over towards a philosophy called constructionism. But we did not stop the disease.

I began frantically studying materials on addiction counseling and delving deeper into the cognitive-behavioral approach. I had previously stayed away from anything related to behavioral because my reading of Skinner seemed to imply that I had to choose between relational and behavioral. I found a new understanding when I learned how to blend those approaches.

My Understanding

The key to my new understanding is that I consider relational, cognitive-behavioral and constructionist-developmental three dimensions in one whole. I pull concepts from each approach without bringing over the whole of each. And I add in a few concepts from elsewhere. So before I can explain how the pieces fit together I need to explain which pieces I chose.

I do not specifically include psychoanalytic in this framework but it is hard to talk about psychology without mentioning Freud. To start with, Freud struggled to explain the way our cognitive mind fails to regulate our behaviors. His best known explanation is that we have an id, ego and superego. Today this same approach is widely used in addiction counseling. Now we refer to these three aspects as the disease, ourselves and our higher power. This is Freudian theory repackaged into everyday language. I also accept the Freudian belief that an external observer can give me a perspective into a problem that I cannot see from within myself.

I include the relational approach from Carl Rogers. In my opinion, relational therapy is based on the idea that the person wants to change. There is an old joke about this. "How many therapists does it take to change a light bulb? Just one, but the light bulb has to want to change." So the approach is simple. I become your mirror. I help you see yourself in a positive light. And this gives you a safe nurturing environment so you can change yourself.

The approach we used on the telephone hot-line was relational. We used phone calls to help people find emotional shelter so they could then make the decision to get professional help. And we gave them emotional support as they struggled with their recovery. This is vital.

I think one of the primary benefits that a new comer gets from going to twelve step meetings is the relationships. Those meetings create a community where addiction is simply a fact of life. The disease infects a person. The person is not the disease and the person's value is not diminished because they are infected.

It was because I did not find relationships in Skinner's writings that I turned away from behavioralism. Thus I avoided Ellis not realizing that the answer I was seeking was there. It was only because the lovely lady had a crisis that I went back to behavioralism searching for an answer. When I read Ellis I found the connection between behaviorialism and relational therapy.

The connection between behavioral and relational goes through cognitive therapy. This short story that I am writing illustrates cognitive therapy. I help people all the time. I feel comfortable working with the homeless and I have helped people in transition. But the techniques I use stay the same until I hit a crisis. My ex-wife's suffering, my neighbor's addiction, my relative's surgery and the lovely lady's distress all created crises. What I had been doing was insufficient. I realized the need for change and I activated myself to change. That is one of the simplest applications of cognitive therapy. I realize my actions are not successful so I change myself.

In my opinion, Rogerian therapy blends relational with cognitive. Rogers did not just chat with people aimlessly. There was a therapeutic objective and the relationship was used as a tool to allow the person to change themselves in a direction that was rational. They thought about the desired outcome, talked about it, assessed and evaluated choices and then acted, cognitively.

When Buber talked with Rogers he asked what Rogers did with the really difficult cases. The implication is that some people are not ready or not capable of choosing a direction for themselves. Rogers replied that relational is still vital. Ellis says the same, but expands on it.

What Ellis found is that sometimes people need to act first and think later. In twelve step jargon this is "fake it until you make it." This is important. If you do not yet know how to think through your actions, then just act the way your advisors tell you to act. Behave first and then think later. After all, if you are caught up in an addiction you are going to act. The question is not whether or not you can spend a couple days thinking about it before responding to that craving. The only question is how you are going to act now that your body is in motion. Ellis' advice is to act in a beneficial way, build that behavior into a habit, and then think about it later. Behavioral actions first, followed by a cognitive, intentional change in thinking.

As I investigated some of the treatment alternatives it seemed to me that many programs are focused on relational and many are focused on behavioral. The danger is that some relational programs offer a warm nurturing environment so the addict can get sober, regain their health and then return to the same addiction refreshed and recharged. The danger is that some behavioral programs crush the spirit of the person in an effort to force compliance. We need to blend these approaches. Relationships offer a safe haven. Behavioral changes habits. Then we need education to explain why those habits need to be self-perpetuating. Relational with cognitive-behavioral provides safety, direction and wisdom.

Now if that was all that I found then the solution would be to just go read more books by Ellis and then Beck. But I think there is more. I believe that the framework I found when working with organizational psychology can allow us to understand how relational fits with cognitive-behavioral. So before I explain what I mean by constructionism and developmentalism, I want to explain how I link relational with cognitive-behavioral.

Two Dimensions

A framework is sort of like a big house. When I say big, I mean a house like people built a couple hundred years ago. Those houses were big enough to hold a family with nine children, a couple aunts, an uncle, some grandparents and a few friends from out of town. We are going to start out with just one part of this house. So imagine that we take a really big saw and cut through this house. Then imagine that we set the front wall off to the side and then we dig down so you can see the basement. A lot of theories about organization psychology use grids to explain the theory. A grid is like dividing things up into rooms. The four organizational psychology models that I liked the best are from "Blake and Moulton", "Hersey and Blanchard", "Vroom, Yetton and Jago" and Tuckman. Two of those models are described in terms of a two-dimensional grid. I found a way to align those grids and treat the other models like they also belong on the same grid.
Following our analogy of a house, the floor that separates the first level from the basement is called the horizontal axis. I use the horizontal axis to describe the relational aspects. Most of what we experience in a relationship is emotional. We have some relationships that are antagonistic and full of conflict. We have some relationships that are nurturing. And we have some relationships that so smother us with love that they are painful. Now just looking at the first floor of this house we can give the rooms names. In my imaginary house the room on the right on the first floor is the kitchen. The room in the middle is the parlor and the room on the left is the nursery.
Applying the analogy of relationships, it can get very hot in the kitchen. So relationships on the far right are antagonistic. And sometimes we doddle over the little ones, so relationships on the far left are smothering relationships. And in the middle life if tranquil. I labeled the vertical axis "dissonance" based on a reading I did years ago. I then used Ellis' reference to Festinger's book on cognitive dissonance to get back to the source of this concept. I believe one of the best illustrations of dissonance is in a classroom run by a good teacher. If we can keep the emotions relatively neutral then the students who are motivated will see and hear things that they want to learn. They will then cognitively realize that there is a gap between what they know and what they want to know. And thus they motivate themselves to learn. So, getting back to my imaginary house, I suggest we stay out of the basement for now. I also suggest we forget about the walls and floors other than just the two that represent the horizontal and vertical axes. I label the room upstairs on the left the bed room - this is where loving relationships are nurtured. The upstairs room in the middle is the study where we go to learn and transform ourselves. And the upstairs room on the right is the work room. By work room I mean that room where everything gets tossed in and tossed about; the kind of a room that is a sewing room, a storage room, an exercise room and a whole lot of those things all at the same time.

The key distinction between all of these rooms is the measure of how we build the relationship and how much we focus on listening to what we need to hear. So if I was going to hold a twelve-step meeting in this house I would get everyone into the study. A good twelve step meeting creates an atmosphere that is emotional welcoming and filled with opportunities to learn. A good twelve step meeting gives us a chance to study ourselves, our lives and our relationships. We want the relationships to be loving, but not intimate. We want people to listen and learn and not just sit in silence. We want to be near the middle of the house where the relationships are trusting and caring. And we need to be upstairs where the dissonance is louder - where it is easier to hear how we want to change.

The people who want to learn will hear something new in every meeting. The people who are complacent will miss the dissonance and thus miss the opportunity to grow. And the people who are resistant will find distractions so they can avoid realizing they are missing an opportunity. By analogy, those who want to learn will come upstairs and sit with the rest of us in the study. Everyone else will lose themselves in one of the other rooms and miss out.

To get people into the study we need to build relationships. Freudian theory uses transference and counter-transference to build the relationship between the therapist and the patient. Rogers and Ellis intentionally build the relationship in order to create a safe haven for the patient. All three approaches then work with the patient to explore the gap - the dissonance - between where he or she now is and where he or she wants to be. All three theories strive for a neutral or warm relationship and all three theories then build on the cognitive recognition of the gap between what is happening and what is desired. All three theories use relationships near the middle of the horizontal axis and dissonance on the upper end of the vertical axis.

Organizational psychology can help us understand how to get people into the right type of space. Organizational psychology does this by way of a model that describes how a team goes through a series of states from formation through to termination. The diagram show to the right illustrates how I arranged the team formation states onto the grid. The horizontal axis is relational and the vertical axis represents dissonance. Team formation theory is relevant because therapy also uses teams. The therapist and the patient are a team and therapy groups are teams. So what organizational psychology tells us about teams is going to help us understand therapy.

Teams begin with neutral, formal relationships. Teams sit politely in the parlor, sip lemonade and make small talk. Nothing important happens, but all teams need to start here.

Next teams enter into the storming state with conflictual relationships. People try to adjust and find their boundaries. By analogy, the team moves from the parlor into the kitchen and things get hot. Many teams never get past the storming stage of development. Many treatments never resolve the conflict between the counselor and the client. But if the team can get through that stage then the friction will die down and the team will become more and more productive.

People start out passively skeptical in the formation state. Then they become angry that their world has been changed and they are no longer in control and find themselves in the storming state. Addiction counselors know this pattern. The value I am trying to add to this discussion is to say that there is a theoretical underpinning behind what addiction counselors intuitively do.

The way to lead a team out of the storming state is by using unconditional positive regard to shift the horizontal axis to the left while increasing the dissonance on the vertical axis. We need to move the team from the kitchen to the study.

When I say "we" I mean those who want to get results. Some people do not want to change and others are afraid. These internal conflicts are often transferred into the therapeutic relationship and this is what drives the conflict that holds the team in the storming state. We need to resolve this conflict and again I turn to organizational psychology for a tool to help solve this problem.

The tool that has the most value here is the model of conflict resolution strategies. I plotted the conflict resolution styles on the diagram shown to the right. In brief - smoothing is an attempt to minimize the conflict and the dissonance. We do this when we pretend that we did not want something that we now cannot have. If you take away a privilege that I value, then I will experience dissonance. I can resolve that dissonance by getting my privilege back. Or, I can resolve that dissonance by denying I valued the privilege in the first place. By analogy, I can just sit in the parlor and pretend like I do not care.

Forcing is all about conflict. When we are struggling with addiction we are in conflict with the disease. Whether we are the addict or a supporter does not matter because both of us are actually fighting the disease. The first of the twelve steps is admitting that we cannot win the battle. When we surrender our will to a higher power we move horizontally away from conflict and come back out of the kitchen and into the parlor.

Confronting is the state where we are transformed. When we confront the problem we minimize the antagonism and then amplify the dissonance. An "intervention" is a loving act aimed at getting an addict's attention. An intervention confronts the problem while loving the person. A meeting is an opportunity to confront the disease by listening to others in a loving relationship.

Compromise is all of the above and none of the above. It is a half-way measure. But sometimes that is all we can get. At least there is less conflict with compromise than with forcing. Compromise is somewhere on the stairway from forcing to confronting.

Withdrawal occurs when we are in chaos. We experience antagonism and we perceive dissonance, but we have no way out. Addicts spend a lot of time in chaos and they share it with everyone they come in contact with. Tough love turns off the dissonance and transitions us from withdrawal to forcing. We then force the addict out of our lives so we can get out of chaos.

States and Transitions

Love with dissonance	Antagonism with dissonance
Aligned state Performing team Aligned resolution -- Utopian goals Expressed in idealism Intimate relationships Transformation state Normal team Confronting resolution Achievement motivation Transformational goal Used in classrooms Empowered relationships Chaotic state Terminated team Withdrawal resolution -- Colliding goals Typical in addiction Dysfunctional relationships Smothering state -- -- -- -- Shown in codependency Dependency relationships Tranquil state Forming team Smoothed resolution -- Inward goals Used in meditation Cozy relationships Conflictual state Storming team Forced resolution Power motivation Unilateral goals Motive for war Coerced relationships Obligated state -- -- -- External goals Shown in enabling Externally defined relationships Distracted state -- -- Affiliation motivation Avoidance goals Escape from reality Tenuous relationships Subjugated state -- -- -- Preservation goals Found when defeated Submissive relationships
Love with distractions	Antagonism with distractions

Notice that I dropped the names of the rooms from this model. I used the concept of rooms to introduce this grid. What I think of when I describe those rooms, however, might be very different from what you think of. For example, I used the name "kitchen" for the room that now corresponds to a conflictual state. I have memories of conflict throughout my childhood in the kitchen. But in your memories the kitchen might be the place where the most intimate relationships were nurtured. So, while naming the rooms was useful to get us to this point I am now going to drop those names and instead focus on the names of these places.

The word that I now use instead of "room" is "state." By "state" I mean a way of being. For example, when I pray or meditate I try to get into a tranquil state of mind.

Most of us want to spend the majority of our time in the tranquil state because it takes less effort. This is the center and almost all of the transitions from one state to another will come back through this frame of mind.

When addiction enters our lives we transition from tranquility to conflict. We begin to feel torn between our desire for peace and the efforts of the disease to take control. We begin a war with the disease. The disease creates conflict with everyone around us. And we start to coerce and manipulate others. We see this in drug addicts. If we stop and look carefully we can also see the same behaviors in the socially acceptable addictions to power and money.

Now if the addictive behavior can avoid the inconvenience of reality then the addiction can live in the conflictual state. Codependency helps block the pain. But reality has an awkward way of creeping in anyway. If friends and family enter the conflict and try to force the addict to see the consequences the addict will hear dissonance. When hunger or illness become severe enough then the addict will feel evidence that life is not going as well as expected. Dissonance drives the addict from the conflictual state into the chaotic state. Life then becomes dysfunctional.

And this is the key difference between the affluent addict who manages to hold things together and the non-functional addict who ends up on skid row. Functional addicts manage to avoid the dissonance that their disease is doing damage. Functional addicts live in conflict with the disease. Non-functional addicts eventually realize that their relationships are dysfunctional.

Addictions are progressive. The disease changes us - against our will and in ways that are not for our best interest. As long as we are in conflict with the disease and with others we cannot change ourselves. When we are in conflict we do not feel safe and we block out reality.

The place where change occurs is in the transforming state. To get there we need to stop fighting and get back to tranquility. There we find peace. Then we can listen to the dissonance and move from tranquility into transformation. Therapists do this by creating a relationship based on unconditional positive regard together with an unrelenting emphasis on the gap between what is and what is desired. Therapists create a safe relationship and then they emphasize the dissonance. Twelve step programs do this in the first three steps.

Teachers do the same thing. Teachers create a non-threatening learning environment. And yet, when a teacher gives out homework assignments there is implied coercion. If the student does not obey then the student will be punished. The reason for homework is to give the student a structured drill that will allow them to practice the required skills. The goal is for the student to then learn the cognitive value behind those exercises. It is the student who learns. Teachers do not teach. What teachers do is create a learning environment. Therapists do not change people. Therapists create an environment that allows people to change. And twelve step programs do not create change - they just guide our efforts away from conflict and towards transformation.

People change themselves when they feel safe and when they recognize the need to change. Relational approaches to therapy create environments where change is safe. Cognitive-behavioral therapy allows us to become aware of the gap between where we are and where we want to be. Doing homework helps students realize the gap between what they know and what they are expected to know. Cognitive therapy talks about the gap. Behavioral therapy helps us experience the gap by going through the motions until eventually our cognitions catch up.

Check Point

Before I introduce the third dimension in this framework I recommend you look over the set of nine states and decide where you are most comfortable. Do you prefer filling your life with distractions like movies, TV and concerts? Are you in the midst of conflict? Have problems turned your life into chaos? Can you find tranquility for some part of every day? Are you interested in transforming yourself - in changing your life? Where are you?

Developmentalism

When I taught classes all of the students experienced the same classroom. All of the students worked the same assignments. And yet, some found the classroom nurturing and some found it threatening. Some valued the assignments and some fought the assignments. We look at each situation through filters we build through our experiences. We each create our own view of reality. The philosophical approach that describes this is constructionism. I came to accept the constructionist perspective by studying developmentalism. So I am going to first explain my understanding of developmentalism and then lead into constructionism. When I previously talked about a house I said it was a big house. And then all I showed you were the front nine rooms. Well, this house has a lot more rooms. What I illustrated earlier is the horizontal and vertical axii. In this next section I am going to describe an axis of depth. Think of this as going further and further back into the house. This dimension of depth is called developmental stages. I found this concept by reading Kegan only to discover that I had already encountered it when I read Erikson. And then I found that Freud had already described this same concept. But the two models most widely recognized are from Piaget and Kohlberg.

Piaget studied children and found that their ability to think is constrained by their mental development. Rules, for example, mean different things at different developmental ages. Loevinger summarized Piaget's observations about rules as follows:

Thinking	Speech clues
"No conception of obligation"
"Arbitrary revenge"	No
"Rules sacred, unchangeable, given by adults"	Why?
"Cooperative rules"	But
"Rules changeable by mutual agreement, founded on mutual respect"	Community
"Interest in rules per se"	Although

As infants we have no concept of rules. We learn from a very early age to live in a world where there are things we can do and things we cannot do without knowing "why". We learn and our mind develops new ways of thinking. Adults who stopped developing at a young age enter into an adult world still thinking like a child. Rules are something that you impose on me after the fact. Rules that are broken without being detected might as well have never existed.

Somewhere around age seven a typical child undergoes a change. Rules stop being something elusive and become something that we learn. Now the "why" behind rules becomes significant. Adults who enter the adult world thinking like a seven to twelve year old accept and honor rules religiously. But not everyone agrees to the same rules. Gangs, religions, organized crime and politics all have their own rules. The rules for the group you join are the rules you respect.

A healthy child in a healthy environment will come to a typical adult understanding of rules if their development reaches that of an adolescent. At this developmental age rules are something that we get together and make up to serve our needs. Once agreed upon the rules become sacred, but there can be exceptions. A larger percentage of the adult population in the USA thinks this way about rules.

Piaget focused on childhood development. It was Kohlberg who extended the research on rules from children to include adult age groups. Loevinger's summary of Kohlberg's stages follows.

Label	Morality
Pre-social
Impulsive	"Punishment and obedience"
Self-Protective	"Naïve instrumental hedonism"
Conformist	"Good relationships and approval"
Conscientious	"Democratic contract"
Individualistic	"Individual principles of conscience"

Piaget did his research by building games and asking children to participate. Kohlberg did his research by giving volunteers morality dilemmas and asking the volunteers to explain why they made the decisions they made. I wanted to put developmental stages to use on a telephone hot line. I could not give the callers scenarios to evaluate so I needed a way to use the scenarios that they presented to me. I found a way to evaluate a person's developmental stage by listening to their "circle of compassion" - a concept I found in the writings of Einstein and Schweitzer. I then went back and studied Kegan again. The tool that I then used on the hotline is summarized in this next table.

Stage	Name	Who do I care about?	Phraseology
0	Incorporative	Me	This is...
1	Impulsive	Extensions of me	Can I...?
2	Imperial	Myself with people as objects	I want...!
3	Interpersonal	Myself in relationship to people	I am...
4	Institutional	One group at a time	You and I are...
5	Inter-Individual	Multiple simultaneous groups	We should...
6	Ethical	Multiple cultures	Humanity is...
7	Moral	Universal	Humanity should...

This model gives me a tool that I can use in casual conversation. It can also be applied to written speech. For example, I studied speeches given by Rev. Martin Luther King, Jr. and found a pattern. I believe his earliest speeches are focused on stage three. In those early speeches Rev. King spoke to his audience with developmental concepts that are common to the USA population. Most adults in the USA typically think with stage three concepts.

I found a progression in Rev. King's speeches from stage three through stage six. In his famous "I have a Dream" speech Rev. King expresses the concept that all humanity will unite. The complexity envisioned in that speech is a vision of multiple distinct and valued cultures working towards common goals. Rev. King grew from stage three expressions to stage six expressions in the interval between 1955 and 1963. Most adults in the USA stop their growth at stage three or stage four. The number of people who reach stage five and beyond is very small. Assuming that Rev. King was on the verge of stage four in 1955 and assuming he just touched on stage six in 1963 he went through a stage transformation every four years. The typical pattern for many adults is to enter stage three in their early teenage years and transition into stage four in their early twenties. That implies there it takes between eight to ten years for an adult transformation. Rev. King was remarkable in that he went through multiple stage transformations in eight years. Most adults never go through another stage transformation after they reach their twenties.

Vygotsky was puzzled by the different rates and levels of development that he found in Russia and suggested that people stop developing when they conform to the expectations in their social group. Most adults have no need to think beyond stage three.

Bronfenbrenner looked at the same concept and then reversed the logic. Bronfenbrenner helped create the "Head Start" program because he believed that negative environmental factors hinder our development. He believed that changing the environment can unlock our ability to learn and to grow.

Constructionism

When my neighbor came to me for help with his addiction I took him to an institution. The "Institutional" model of treatment was the most common model from the mid-nineteenth until the mid-twentieth century. That model is still very common. The basic concept is that we cannot do anything about addiction, but there are professionals that can. So we need to just lock up the addict, either to protect us or to reform them.

When I worked with my relative to try to schedule her son's surgery I followed the "Will Power" model. I thought she just lacked the will to make the right choice when both alternatives had risk. This is probably the most common model today when you talk with someone about how to treat addiction. I know that I spent a lot of time arguing with my lovely lady telling her to stop.

What Bill Wilson found in 1935 is that will power does not work. And so he started Alcoholics Anonymous and was a key contributor to the "Disease" model of addiction. The basic idea behind the disease model is that we are fighting an internal battle with an unseen enemy. We can even personify this enemy and hold mental conversations with it.

I now see that this model has limitations.

First, if we put the disease in remission and the symptoms disappear, then the disease model is right. But the addictive behaviors do not stop. Even when an addict is dry they are not healed. Remember I mentioned earlier that a common explanation is to say that an addict's development is halted when he or she starts to use. Well the effects from that arrested development linger even after the diseased behaviors cease.

Second, the developmental ages that I find in some of my addict friends are from developmental stages one and two. Now, if people progress in a fairly typical pattern then they will travel through stages one and two before they become teenagers. And very few addicts get addicted before they should have reached stage three. It was this observation that caused me to pause. What if it is the development that stops first and addiction is simply a flawed attempt to treat the underlying cause? Think about the dissonance that will be created if you are trapped in stage one thinking while the world expects you to be in stage three. Think about some five year old that you know. Now drop that five year old off at a middle school and see how well he or she fits in. Think about the rejection and torment that children inflict on each other when they do not conform. How would you deal with that pain? What coping mechanism would you choose?

These two points led me to the belief that addiction is a symptom. I now think the disease is a bundle of symptoms. I think the underlying cause is a disability. And thus I came to realize:
 

Addiction is often a flawed treatment method for a disability in thinking.
 

Observations on Treatment

• As everyone involved in treatment knows many laws and much of public opinion is still focused on the "Institutional" treatment alternative. Many people want all addicts to go to jail or at least into a lock-up facility. I used to think this was best for the addict. Now I see that institutions do not stop the disease and do little about the underlying cause.
• I know many people who work their recovery using the "Will Power" model. They have been sufficiently conditioned to stay clean in order to avoid more institutional time. Or they have strong enough incentives to be self-motivated. But it is my opinion that the people who succeed through will power are otherwise "functional'. In my opinion, if you stop the symptoms of the disease and you return to "normal" then you were probably pretty close to "normal" before the addiction started. Twelve step programs and outpatient treatment work well when the person is a functioning addict.
• I see many people who treat their addiction as a disease and settle comfortably into a life of twelve step work. Many of these people seem to be "dry addicts" - people who continue to display all of the addictive personality except they do not use.
• I hear about treatment programs that focus on the disease model and have great success at treating the disease. But I question some aspects of these programs. For example, I see an inconsistent treatment model when I hear about a person who goes into treatment with a stage one or stage two concept of morality and is punished for failing to honor the rules. I think the "Disability" model should be considered instead.

If someone has an understanding that rules are socially defined and that person chooses to disobey the rules, then that person is practicing "civil disobedience". Rev. King, for example, knew the consequences and chose to disobey various laws on purpose. But people who think in stage one or stage two do not disobey for a greater good, they disobey because in their mind the rules do not have value. How then does the treatment program respond?

• I hear about treatment programs that send recalcitrant patients off to prison. I find this a contradiction in models. The person was sent to treatment because we think the disease model is right. So sending the person to prison for failing to follow the rules implies that we want the public to follow the disease model while those doing the treatment want the option to fall back on the institutional model when it is convenient.
• I hear about treatment programs that have people write the rules down on paper over and over again rather like a nineteenth century classroom punishment. The goal in such efforts is to help the person understand the rules and thus motivate the person to exert more will power. Again, this is a contradiction. We have treatment programs because will power is not sufficient to treat a disease. So a treatment program focused on will power is a treatment program that does not follow the disease model.
• I hear about treatment programs that have grace and respond to the rule-breaker with an understanding that it is the disease that is causing the errant behavior. And yet, I know many addicts that have gone through such grace filled programs only to return to their addiction. Once the disease is in remission then the disease has to be taken off the list of suspects. There has to be another reason why people keep breaking the rules.
• And thus I came to believe that the reason many addicts break rules is because their conceptual development was arrested long before they became addicts.

A Three Dimensional Approach

The first thing I need to do is more homework. I have read Piaget but now I need to go back and read his book on morality. I have read Kohlberg but now I need to go find those books and read them again. I need to study more about addiction counseling and work towards certification or licensure so that I have experience from the inside. I also need to get feedback on this approach. And that is why I am distributing this paper. I need your feedback.

Now, when I write a paper like this I always give myself homework assignments. I also want to give you one. I want you to consider the vast range of topics that I have presented in this paper and find a way to bring them all together. The exercise of juggling these topics will help you grow new constructs. And, while I wish I had a magic formula to help you grow into a new developmental stage, it seems that triggering a stage transformation is elusive.

Thus, if neither you nor I can give ourselves a homework assignment to trigger a developmental stage transformation, I wonder why we expect addicts to go through one in a three or six month program? It took Rev. King about four years per transformation and he was a remarkable person. I believe I have gone through a couple adult transformations and it seems like it takes me at least ten years for each transformation.

The best advice I can offer on developmental stage transformations is as follows:

• We need to create a safe, non-threatening environment. Relational therapy has tools like unconditional positive regard that can assist us.
• We need to relentlessly but gently value the gap between where we are and where we want to be. Cognitive-dissonance is an internalized sense of this gap. If the dissonance is too high or if the environment is not safe then we flee. Cognitive therapy helps us hear the dissonance. Behavioral therapy helps us feel the dissonance. I value the blending of those approaches into the cognitive-behavioral approach.
• We need to work on mental concepts and help each other construct a more integrated view of reality. We need to accept each other at the developmental stage we are in. We can undergo a significant constructional transition in a few months. We need years of effort before we might expect a developmental transformation to occur.

And then I recommend that we do unto others as we would want them to do to us. I want to experience another developmental transformation because each brings me closer to the ability to find my place in this world. I want others to have the same understanding of community that I have. I want everyone to understand that this community needs each of us to play by the rules. But until my addict friends can reach that understanding I need to value you them where they are. And some of my addict friends are trapped in the self-serving views of stage one or two.

Conclusion

Post Script 1

White then describes the Freudian techniques that were used to try to resolve the underlying cause and explains why this failed. I believe that treatment techniques have made great progress since then. In my opinion the process widely used today is sequential.

1. First treat immediate medical issues such as physical trauma.
2. Then do a detoxification.
3. Next use treatment to put the disease into remission.
4. And then address the underlying causality.

The Freudian psychotherapeutic approach focused on underlying causality and presumed the disease would thus be cured. The point I try to make in distinguishing between cognitive, constructionist and developmental growth is that of timing. Cognitive-behavioral therapy can implement changes immediately. Constructionist changes can occur in a matter of weeks or months. But the underlying developmental causes are unlikely to be cured quickly and might not ever be resolved.

I have two concerns about focusing on the disease model without acknowledging the disability model. My first concern is that the disease model only addresses the first three treatment goals and ignores the fourth. My second concern is that I hear stories about a focus on the disease that seems prejudicial against those suffering from a disability.
 

Post Script 2

Punishment - make me do something I do not like. Examples are lock-ups, jails, prisons. But we do this all the time in such simple things as giving students extra homework, giving our children extra chores or withholding our affection from someone we love.

Will Power - motivate me. I can motivate myself with an internal desire or you can motivate me by offering me some reward. Examples are the will power it takes to stay in a treatment program or stay in a relationship when things get tough. Rewards can be the promise of a better future, or the ability to earn a privilege.

Disease - make the symptom go away. This is why we take aspirin. This is what addiction treatment is designed to do. But let me illustrate this with another example - anger management. Try this exercise. When you get angry, quickly grab some paper and write down what it is that you are angry about. Guess what, those couple seconds it takes you to think about it and write it down might be all it takes to help you get it under control. Do this every time you feel anger for a week. Then, the next week write down not just WHAT, but WHY. Why are you feeling this way? The third week, think about what, why and then think about what you can do instead. And you might not even need the paper if you can do it in your head. You do this and you will change the way you act. (McKay, J; R;, Rogers, P; D; and McKay, J;).

Disability - treat the real problem. We do this by looking inside. Working the 12 steps gives us a way to search inside ourselves for answers. We can also search inside ourselves by working at being a really good Christian. Personally, I find that writing and teaching are the tools that help me search inside myself because I cannot explain it to you until I figure it out.

Now, if I tell you to write a paper about something then I am punishing you. But, if I ask you to write a paper about yourself, then I still punish you by giving you extra work. But I also ask you to focus your will power into doing something that will help you get better. And I give you an opportunity to study the disease and find your own remedy. And I give you an opportunity to study you and find out why you are who you are. What makes the difference is in how you interpret what I say. Am I forcing you or am I guiding you? You treat the disability when you become part of the effort.
 

Post Script 3

You look in the freezer and see some ice cubes. Hard cases. So you put them on top of the refrigerator for treatment. Sure enough, when you check back the next day you see that treatment worked. So, now that these cubes have been treated you pop them back in the freezer. But the tragedy is that those ice cubes relapse every time. Then we blame them instead of blaming a world that is too cold and uncaring.
 

Post Script 4

We can use wood to build a building that is five stories tall, but if we try to build a twenty story building with wood we run into problems. Bricks work well with a twenty story building but the design of a building made with bricks is very different from the design of a building made from wood. And bricks have their limits as well once you try to build a one hundred story building.

Now if we wanted to build a one hundred story building out of steel and glass we would most likely tear down the brick twenty story building. But in our minds we preserve the old structures and then build new structures over top. It is as if the wooden five story building is inside the twenty story brick building which is now enclosed by a one hundred story steel structure.

The structural designs required to understand rules and morality like a child are very different from the structures used by teenagers and adults. But adults can still think and act like teenagers and teenagers can still think and act like children.

An addict who goes through a spiritual transformation and reaches a more mature understanding of himself or herself will work with the new structures - as if the steel building is all that exists. In times of stress we often regress back to prior behaviors. But all of the work that we invested in the new structures is not lost. Getting back from addiction to recovery is a challenge, but the foundation and stability of the recovery that we come back to is based on the new structures - the new ways of thinking.
 

Post Script 5