Addiction Treatment: Why Individual Sessions are Important
by Tom Horvath, PhD, ABPP
Why individual sessions in addiction treatment are important
One of the most frequent complaints I hear from clients who have attended other treatment facilities is “I almost never had an individual session.” Why are frequent individual sessions unusual in US addiction treatment, and why are they important?
Groups led by drug and alcohol counselors save money
A business reason to provide treatment primarily in groups is to lower costs. All businesses want to save on labor costs. In many cases groups are oriented around a well-established curriculum, designed to help clients “get the program.” Getting the program typically involves accepting the perspective that “I have a disease, I need to go to meetings for the rest of my life, I can never drink again, my own willpower will never be sufficient to solve my addiction problems, etc.” From this perspective individualized care is not needed. Every recovery looks essentially the same.
If getting the program is the goal of the group, then additional savings can occur when the group is led by a drug and alcohol counselor. Most addiction treatment is provided by these counselors, who can be employed at lower cost than physicians, psychologists, social workers and licensed professional counselors.
By comparison, what would you think of a healthcare facility that provided most of its medical care with vocational nurses, and only occasionally allowed the patient to see registered nurses, physicians and other high level professionals? In that scenario there would be little individualized care. Everyone on the cancer ward would get the “cancer program.” Vocational nurses have a critical role in health care. However, how much authority should they have in making health care decisions? Would you not want your medical care fully individualized? Similarly, how much authority should drug and alcohol counselors have in addiction treatment?
How did our society arrive at the current situation, in which addiction treatment is so dramatically underfunded? Ironically, viewing addiction as a disease sets us up to stigmatize those who have it, and thereby rationalize not providing high level care for them. In my darker moments I view the treatment often provided in the US as akin to the low quality medical care (if any) probably provided to most slaves throughout history.
Individual sessions can provide truly individualized care
Indeed there are excellent drug and alcohol counselors, but their training does not prepare them to address the critical issues that can arise in addiction treatment. These critical issues are why individualized care is needed.
There are as many ways to overcome problematic addictive behavior as there are individuals. It is the role of the professional to help the client determine, given the biological, psychological and social changes that might be made, what makes sense to move forward with.
Some of this decision-making can be accomplished in groups, if these groups are facilitated by a high-level professional. It can be enlightening to participants in a group to observe others address issues that are probably similar to their own: What are my motivations to change? How do I respond to craving? Am I depressed, anxious, angry, guilty, ashamed, etc., and how do I address these negative feelings so that I do not return to addiction problems? How do I give long-term satisfactions an adequate role in my life, after I have been living with such a strong focus on short-term satisfactions?
If a client will attend groups there can be many advantages to them. However, in my experience there are two primary objections to groups: “I don’t want to spend my time listening to other peoples problems; I’m not going to discuss my personal business in front of a group of strangers.”
Early in the process of change it is unrealistic to expect someone to recognize that there can be great benefit from listening to the problems of others, and that opening up about one’s secrets to a group can be even more healing than doing so to just one therapist. However, one less-than-helpful group experience can be enough to sour someone on the value of group for a long time, and such experiences are common when the group is not led by a high level professional who is experienced in leading groups.
It is often challenging enough for the client to be sufficiently introspective and forthcoming in an individual session. Furthermore, if their situations and problems are complicated, as they often are, a group will not have adequate time to address the issues and consider solutions.
All addiction treatment cases are “serious”
Individuals in addiction treatment are the tip of the iceberg of individuals with problematic addictive behavior. The rest of the iceberg takes care of itself, in most cases, via “natural recovery,” which is to say that most individuals resolve their problems without entering treatment. Individuals who enter treatment often have substantial levels of problems, which have made natural recovery unlikely. Individuals in treatment need significant professional time to help them develop and follow through on a process of change.
In medical care we place the serious cases in the hospital and treat the rest as outpatients. I suggest that clients in any level of addiction treatment are the equivalent of hospitalized medical patients (and in both cases ICU’s can be needed). In both cases high-level attention needs to be paid to them. In addiction treatment high-level attention means individual (and couples and family) sessions, conducted by high-level professionals, supplemented by groups if the client will accept them.
Despite how inadequate most US addiction treatment is, many individuals nevertheless demonstrate impressive resilience and gain some benefit from it. However, a focus on individual sessions and truly individualized solutions would make treatment much faster and more helpful for many.