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Clinical Philosophy - Full Version

 

Introduction

The Clinical Philosophy describes the core beliefs and values that we hold regarding our understanding of addiction, its resulting treatment approaches and its program implications.  These clinical values and beliefs are to support and achieve our mission which is “to support change in the lives of individuals, their families and communities related to substance use and gambling”.

 

Clinical Philosophy

Our clinical philosophy embraces a holistic perspective of addiction1 in both its etiology and the resulting treatment approaches.  Addiction is a set of behaviours resulting from a complexity of interactions between biological, psychological, social and spiritual factors2.  The various aspects of addiction must be considered simultaneously. 

We acknowledge that it is important not only to focus on addictive behaviours themselves, but to focus on the person in whom the addiction arises. A holistic2 approach places the person at the central point of focus. The person is bigger than, and is not defined by, the addictive behaviour.

An individual suffering with an addiction needs to be viewed within the context of a system of relationships, including their multigenerational family system, societal and cultural systems.  As a result, addiction is defined in relational terms, as an unhealthy relationship between the person and the substance/activity where addiction becomes a coping mechanism, perpetuating negative consequences and their recurrence.  We believe substance use/activity acts as a medium to provide temporary relief from overwhelming experiences. 

 

The Elements of Addiction

The bio-psycho-social-spiritual model (Diagram 1) suggests that biological, psychological, social and spiritual factors all play a significant role in understanding addiction.  The following will briefly describe the elements of addiction.

Biological Factors

An individual is not only vulnerable to genetic factors, but also to many substances of abuse, such as alcohol and drugs, as well as behaviours such as gambling, which have a direct impact on the brain’s functioning. Drug use and addictive behaviours effect change in the brain, which results in the compulsion to engage in repetitive, high risk behaviour.  Research shows that addictive behaviours impact core brain components which control motivation, physical and emotional senses, stress regulation and the capacity to feel and receive love.  Research has further evidenced that deficits in attachment processes, such as the provision of a nurturing environment in the primary stages of development, alters crucial brain circuit development; which may create a predisposition to developing addictive behaviours (National Institute on Drug Abuse, 2008, 2010; Khantzian 1999/2007, 2008).

Psychological Factors

All components of addiction involve the influence of emotional and psychological dimensions. People who have experienced emotional distress or trauma are more susceptible to addiction, as they attempt to alter difficult emotions or to create different emotions by seeking something outside of themselves (Maté, 2008). Addiction can act to re-establish a sense of self-regulation and control of one’s affective state, resulting in a sense of control and power that has been lost or taken away. However, even though noxious substances, alcohol, and behavior, such as compulsive gambling, may serve to achieve ‘pleasure’ at first, subsequently, they are used to ward off pain, such as withdrawal and triggers from painful memories (Khantzian, 1983, 1999/2007).  Addiction may be an indicator of experience rooted in childhood trauma, unmet psychological needs, losses, grief, attachment issues, feeling of powerlessness, etc. Addiction requires compassionate attentiveness to what is happening within (Maté, 2008).

Social Factors

Social and environmental factors tend to have a significant impact on the risk of developing addiction. An individual’s interaction with their social environment, including family and peer networks, societal beliefs, and cultural diversities, contribute to the onset, maintenance, and relapse, of and, to addiction and/or addictive behaviour. Rapid economic and technological advancement have impacted the social culture globally. Despite economic improvements, it can equally create social marginalization. Political, economic and social changes can impact families, communities, and cultures and create exclusion, isolation, powerlessness, and dislocation. As well, other social factors such as race, gender identity, sexual orientation, age, ability or culture can result in oppression, prejudice, exploitation, marginalization or even violence. People and communities who are consistently in a position of disadvantage are vulnerable to addiction. On a micro level, social changes can affect the family system, relationships and the structure of authority within the family. Also, the increase of peer influence can intensify the vulnerability of younger generations to addictive behaviour.

Spirituality Factors

Spirituality is a basic aspect of human experience and development, common to all people, cultures and religions.  It is an essential part of an individual’s worldview and the meaning of his or her existence and identity. Spirituality provides a protective perspective for many people, which allows them to interpret their experiences and to make sense of their world. For many people this functions as a relational link to oneself and with others.  For some, spirituality is an integral part of their cultural belief system which gives them a sense of identity and belonging. Thus, spirituality often keeps people committed to working through the struggles and pain they encounter in life.  A restoration of this aspect of life may be important for people who are being challenged with addictions. 

Spirituality is woven through the bio-psycho-social factors. It is not the intent of the agency to describe what spirituality is and what it should mean for individuals. However, the hope is to provide a space for individuals to explore this aspect, if they wish, which might lead to a better understanding of their struggle with addiction. We recognize that clients may have diverse spiritual needs and so we wish to encourage them in their individual quest(s) for spiritual growth and development as an important component of understanding their addiction.

 

Diagram of Bio-Psycho-Social- Spiritual Model of Addiction©

Diagram of Bio-Psycho-Social-Spiritual Model of Addiction©

 

Relationships between Biological, Psychological, Social and Spiritual Factors in Addiction

There is a vital link between the various components of addiction.  Research has evidenced that due to the complexities of the human condition, interactions of brain, mind, and body, with internal and external environments, influences addictive behaviour. All of these factors and their mutual interactions need to be considered in understanding addiction. The mind and its contents of emotions-profoundly interact with the body and the result is a measurable set of physical events in the body, involving the brain, the hormonal apparatus, and the immune system and down to the cellular level (Maté, 2008). There is a circular relationship of addiction and life experiences (Figure 2).  The impact of negative or traumatic life experiences, especially during the primary developmental stages can greatly increase a person’s vulnerability to addiction. Addiction can further impact a person’s psychological and neurobiological environment placing the individual in an increasingly vulnerable position to more traumatic life experiences.

 

The Cycle of Bio-Psychological Factors

 

It is not the substance that defines an addiction, but the person’s relationship with the substance, with the self, and with others, which is at the heart of the matter.

Physical dependence on a substance is neither necessary nor sufficient for addiction to occur. Psychological factors are an essential aspect in understanding addiction. The addictive behaviour constitutes a sequence of interactional events which occur at three levels:  relationships between the person and the substance/activity, the person and self, and the person and others (Bepko & Krestan, 1985) (Figure 3).

The relationship between the person and the substance is typically related to a failure to self-regulate. This need often originates from interrupted, fractured or fragmented attachment processes that occur during the primary stages of development.  The experience is one of pain, loss and grief. A deficit in one’s primary sense of self-preservation, accompanied by fears of powerlessness and lack of control over one’s biological, psychological, social and spiritual environment, can compel an individual to turn to external sources to satisfy this need. 

Substances/behaviours can create pleasurable experiences; or, remove negative experiences, such as physical or emotional pain. This process serves as a corrective function, which relies on external sources to provide a sense of relief, escape or defence against painful memories.

The substance/behaviour can develop into a primary relationship. This can occur on a continuum from mild to severe, until it takes on a life of its own to the exclusion of other significant relationships. At this point, the relationship is often characterized by power and control. The person may believe they have power and control over their substance use/behaviour. If this fails, however, it triggers feelings of helplessness.

The relationship between the individual and others includes relationships with family, society and the culture within which the person is a part of.   People express the history of their multigenerational family systems as well as broader society and culture.  Addiction then is a manifestation of such historical information that helps us understand the interactions of the biological, psychological, social and spiritual components.  From a systemic perspective, once substance use has become a central focus of concern in a system, such as in a family, other members of the system adapt to the full sequence of the substance user’s behaviour and become caught in the maladaptive cycle.  The substance shifts the system by regulating the boundary, emotional distance, power distribution, roles and responsibility between members.

It is important to examine the complex interactions between a person's biological make up and their social environment. Social determinants of physical and mental health and biological determinants of social positioning are important in understanding addiction, the development of addiction, prevention and intervention/treatment strategies3.

Some of the social variables include gender, culture, race and socioeconomic status. These factors shape the distribution of economy, power and resources at all levels which then directly impact physical health, mental health and a person's vulnerability to addiction4. For example, being members of subcultures who may experience multigenerational exploitation can lead to addiction of the entire community.  From a cultural perspective, modern technology and consumer culture encourage immediate gratification and for solutions from external sources.  These types of cultures may set the tone of avoidance, or disconnection with internal experiences, which factor in the development, and perpetuation of addiction.

Biological variables, such as mental or physical health challenges place individuals at a higher risk of being placed in positions of economical disadvantage.  Feelings of powerlessness to access opportunities and resources increase vulnerability and susceptibility to addiction.

 

Diagram of Bio-Psycho-Social- Spiritual Treatment Model of Addiction©

  • The person is the centre of treatment. The focus is not only on addiction, but the whole person.
  • Systemic intervention addressing bio-psycho-social-spiritual aspects of addiction.

Diagram of Bio-Psycho-Social-Spiritual Treatment Model of Addiction©

 

Circle of Care

Even though staff and programs have a particular area of specialization and focus in their delivery of care, they are mindful of the multiple aspects of addiction from a bio-psycho-social-spiritual approach.  Holistic treatment can be carried out through multiple programs where there may be a concentration of focus on biological, psychological or social aspects of addiction.  All programs work together to provide comprehensive and complimentary care to our clients.

Based on the service focus of each program, staff apply different skills to provide a Circle of Care to our clients. Staff self-care and a supportive working environment are essential for the success of the services.

Addiction Services for York Region Circle of Care

 

1. Our agency acknowledges that the term addiction can be interpreted as being stigmatizing. It is not our intent to perpetuate stigmas associated with this term, but rather we hope to use addiction as a term to encompass different behaviours associated with substance misuse and gambling behaviours.

2. The Government of Canada has endorsed a multifactoral bio-psycho-social model called the Determinants of Health. It has used this model to develop the Health Promotion Strategy and Canada’s Drug Strategy.

3. Canada’s Drug Strategy (Government of Canada, 1998) states that prevention, treatment and rehabilitation programs must consider the determinants of health and address the underlying factors associated with substance abuse.

4. According to the World Health Organization, the established key factors which influence population health and mental health are: income and social status; social support networks; education; employment/work conditions; social environments; physical environments; personal health practice and coping skills; healthy child development; biological and genetic endowment; health services; gender; and culture. 

 

References

Addiction Foundation of Manitoba. (2000). A Biopsychosocial Model of Addiction.  Addiction Foundation of Manitoba.  Retrieved from:

http://www.google.ca/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CCYQFjAA&url=http%3A%2F%2Fafm.mb.ca%2Fwp-content%2Fuploads%2F2013%2F03%2FBPS-FINAL.pdf&ei=vqcPU9HUBOS02AWe84C4Dw&usg=AFQjCNGvPG-E1874Qv5YI5NHmwf69xEgQQ&bvm=bv.61965928,d.b2I

Bepko, C. & Krestan, J. (1985). The Responsibility Trap. The Free Press A Division of Macmillan, Inc. New York, Collier Macmillan Publishers London.

British Columbia Centre of Excellence for Women's Health Publications. (May, 2013). Trauma Informed Practice Guide. Retrieved March 20, 2014 from the British Columbia Centre of Excellence for Women's Health website at:

 http://bccewh.bc.ca/publications-resources/documents/TIP-Guide-May2013.pdf

Government of Canada. (1998). Canada’s Drug Strategy. Minister of Public Works and Government Services Canada.

Khantzian, Edward J. (1983). Self-Preservation and the Care of the Self – Ego Instincts Reconsidered, in the Journal of Psychoanalytic Study of the Child 38:209

Khantzian, Edward J. (1999/2007). Treating Addiction as a Human Process. Maryland: Jason Aronson.

Mate, G. (2008). In the realm of Hungry Ghost: Close Encounters with Addiction. Alfred A. Knopf. Canada.

National Institute on Drug Abuse.  (2008). Comorbidity: Addiction and other Mental Illnesses in Research Report Series. Retrieved from:

http://www.drugabuse.gov/publications/research-reports/comorbidity-addiction-other-mental-illnesses

National Institute on Drug Abuse.  (Revised 2010). Drugs, Brain and Behaviour – The Science of Addiction. Retrieved from:

 http://www.drugabuse.gov/publications/science-addiction   

Substance Abuse and Mental Health Services Administration.(2014). Trauma-Informed Care and Trauma Services. Retrieved March 20, 2014 from the SAMHSA website at:

http://www.samhsa.gov/nctic/trauma.asp

Jean Tweed Centers, (2013) Trauma Matters:Guidelines for Trauma-Informed Practice in Women’s Substance Use Services.

World Health Organization. (2012). The Rio Political Declaration on Social Determinants of Health. Retrieved from:

http://www.who.int/sdhconference/declaration/en