An Integral Foundation for Addiction Treatment Beyond the Biopsychosocial Model
Guy Du Plessis, in this pioneering effort, provides us with an insightful analysis and an erudite review of the reasons for the current crisis in addiction science and treatment services. It is accepted that existing treatment programs do not fair better than untreated population in terms of outcome and yield high relapse rates following completion of treatment. This, according to him, necessitates a paradigm shift, due to definitional confusion and ineffective treatment philosophies. Efforts to integrate divergent models conceptualizing addiction have failed so far, especially holistic models like the Biopsychosocial (BPS) model. Furthermore, it has been suggested that the low success rate for addiction treatment is because substance abuse programs apply partial and outdated treatment models. The cornucopia of theories and models of addiction have made it exceedingly difficult for treatment providers and policymakers to integrate this vast field of knowledge into effective treatment and prevention protocols. The author proposes applying an innovative strategy based on Wilberian integral metatheory (after Hargens & Wilber) to solve the problem, and proposes his own Integrated Recovery Meta therapy or (IRMt).
Over the five chapters of his book, the author argues convincingly the need for change and defends his theory elaborately. It should make a pleasant and educational reading to everyone working in the addiction field or who has been affected by the disease. His critique of the aetiological models of addiction i.e. polygenetic, physiological, and environmental (macroeconomics changes and dysfunctional family environment) is comprehensive and up-to-date. Also a brief summary of Coping and social models, personality and intrapsychic models like narcissistic disturbance of self-experiences and painful affect states, fantasy-based self-psychological model of addiction (self-hypnosis) metamorphosis or transmogrification, etc. is very informative. In this review, a summary of the book is provided and, inevitably, many parts of the review are direct quotes to entice the reader to refer to the origin and also as a complex theory it necessitated delivery of the original text to avoid misinterpretation or representation. His book is inclusive and an invitation to unity and followers of the transtheoretical model and 12 steps programs would be find a fair and positive view of their approach but the author decides it is a partial approach and does not provide a truly holistic framework or method.
(IRMt) What it is and what it is not?
The conceptual metatheoretical framework of addiction is referred to as “an integral foundation of addiction” or integral metatheory of addiction. When working with addicted populations the meta-therapeutic framework for therapists is called (integral meta-therapy). Integrated Recovery Meta therapy (IRMt), according to the author, is a metatheoretical framework to apply counseling, coaching, and psychotherpy techniques in a structured and integrated way to maximize the recovery and development of people living with substance abuse and addiction”. The architectonic of the metatheory is based on Ken Wilber’s integral theory (the AQAL model) which has been applied in over 35 disciplines. AQAL represents all quadrants, all levels, all lines, all states and all types; signifying some of the most basic repeating patterns of reality. The author threads together Esbjörn- Hargens triadic notion of integral pluralism where three pluralisms that are explicit within integral theory are identified, namely, epistemological, methodological, and ontological. Enactment is the bringing forth of certain aspects of reality (ontology) when using a certain lens (methodology) to view it. Applying these, pluralisms, with Enactment we can understand why different theories of addiction do not have to contradict one another.
IRMt is principally informed by two philosophical foundations. The first is an existential foundation that defines our being-in-theworld or our recovery-in-the-world, and the second, an overarching metatheoretical foundation informed by integral theory. The author provides a thorough digest of existentialism movement from its influential philosophers such as Søren.
Kierkegaard, Friedrich Nietzsche, Martin Heidegger, and Jean- Paul Sartre and 20th century existential therapy thinkers Ludwig Binswanger, Otto Rank, Medard Boss, Viktor Frankl, Rollo May, Karl Jaspers, and Irvin Yalom. His reasoning is that “most of the models of addiction have as their foundation a natural scientific worldview and positivistic methodology, which are typically adequate for exploring phenomena that exist on a certain level of ontological complexity: primarily denoting the physical realm. However, such models are hopelessly inadequate in explaining complex phenomena such as addiction or any human behavior, which exist on higher levels of ontological complexity.
Various templates and tools are used in IRMt: the integrated recovery program template, the integrated recovery wheel, and the integrated recovery indices. These recovery tools also serve an underlying psychodynamic purpose for recovering addicts. The structure of an integrated recovery program can help satisfy the need for ritual and rigidity in a healthy way and once this recovery structure is internalized, it will help build much needed psychic structure. According to Du Plessis “IRMt is more suitable for those clients that have completed the primary/acute phase of their treatment and for those that acknowledge their addiction and need for a recovery program”.
What it is not
Dr. Du Plessis makes two important disclaimers. First: “the book does not attempt to provide a better solution to the problem of addiction and the treatment thereof. Its aim is simply to lay down the tentative outlines of a philosophical and conceptual foundation of addiction that may have the potential for theoretical integration and improving treatment outcomes.” The second disclaimer is: “many of the ideas that are presented in the book are undeveloped and tentative, and require further investigation and critique.”
The framework provides the “conceptual scaffolding” for a therapist, but does not indicate what methodology to use. Therefore, applying integral theory to therapy is best understood as a meta-therapy, in the sense that it provides a multiperspectival and metatheoretical perspective of the therapeutic process when guiding addicted clients in their recovery process.
Why is it Needed?
The purpose of the book as the author states is to resolve the conceptual chaos, the ineffective interventions, and to provide a new methodological, ontological and epistemological (the worldview or the bigger picture a “Weltanschauung”) understanding of addiction, and then apply it to addiction treatment through IRMt. Locating “a single neurological condition [or] mechanism” as the primary causal factor of a variety of diseases illustrates the reductionist conception to attribute “the material of the body (biology) alone for explaining our minds and behaviors”.
The Architectonic for an integral foundation
Du Plessis sets himself the task of laying down the foundation for an integral metatheory of addiction that:
• Should provide an integrative conceptual etiological taxonomy and include the developmental stages of addiction.
• Provide a framework for understanding addiction as a multiple object on a continuum of ontological complexity (ontological depth and span).
• Should be consistent with empirical observations of addiction made by clinicians and researchers, and with the phenomenological experience of addicts.
• Moreover, it must be relevant for treatment protocol development.
IRMt views an individual’s recovery-in-the-world through six lenses called the recovery dimensions. The six recovery dimensions are influenced by the quadrants of integral theory and Max-Neef’s theory of human scale development. The six lenses are: physical, intellectual, psychological, existential, social & environmental. These six interrelated yet irreducible recovery dimensions provide a multiperspectival hexagonal framework on an individual’s therapeutic process. According to IRMt, it is vital that these six recovery dimensions of a client are maintained at an essential level of health for sustainable recovery. If there is pathology in any of these areas the whole recovery system suffers. Clients are assisted by their therapists to find and apply suitable therapies and recovery practices in each of these dimensions. The compilation and action plan of these recovery therapies and practices is defined as the client’s integrated recovery program.
According to integral theory, reality has at least four irreducible perspectives, which must be consulted when attempting to fully understand any aspect of reality: the subjective, intersubjective, objective, and interobjective. These four universal perspectives are known as the quadrants. Any treatment program will be incomplete if it does not account for all four quadrants in its therapeutic understanding and design.
Presented diagrammatically, the upper right quadrant deals with dysfunctional brain physiology. Addiction affects the mesolimbic system of the brain (medial forebrain bundle), the area where our instinctual drives and our ability to experience emotions and pleasure reside.
It is indubitable, still quoting the author, that addiction has a significant biological component, but to reduce addiction to neurophysiology (for example the “brain disease” model) would be a gross error in assigning addiction an ontological status that is not befitting of its true complexity. Upper-Left Quadrant perspective includes the subjective dimensions of individual consciousness. Addiction has disastrous consequences in the addict’s inner phenomenal world cognitively, existentially, and emotionally. The Lower-Left Quadrant is the “we” space or perspective and includes the intersubjective dimension of the collective. Addiction may be viewed as an intimacy disorder as addicts often have an inability to form healthy intimate relationships. Lower-Right Quadrant the interobjective perspective of systems, addressing observable aspects of societies such as economic structures, civic resources, and geopolitical infrastructures.
According to integral theory, and to understand the lines of its development, each aspect of the quadrants has distinct capacities that progress developmentally; these are known as lines of development and each person has multiple lines of development. Each quadrant comprises many lines of development; for example, the Upper-Left Quadrant includes cognitive, emotional intelligence, spiritual, moral, interpersonal, and so forth.
Early stage recovery refers to the stage where the focus is on abstinence and relapse prevention. Middle-stage recovery is where the focus is on working through various psychological issues and behavior patterns that often predate the onset of addiction. In this stage of recovery, many addicts also begin to work on codependency issues, relationship issues, and behavioral addictions, which tend to surface once their substance abuse has been addressed.
“In addition to levels and lines there are also various kind of consciousness states associated with each quadrant. States are temporary occurrences of aspects of reality”. Using substances or engaging in any mind-altering behavior is an attempt to create an altered state of consciousness (ASC), and the specific psychoactive effect of various drugs and mind-altering behavior creates various types of ASCs .It follows that viewing addiction in terms of an ASC perspective is crucial for a complete understanding of the nature of Addiction.
This book comes at a critical time for addiction science. Substance use is reaching unprecedented levels worldwide with unimaginable consequences for individuals and societies. Behavioral addictions are being added to the portfolio of addictions (gambling included in DSM-5 and gaming in the upcoming ICD11 with sex, food pending.). Current interventions are yielding minimal benefits leading to testing questions for service provision by policymakers and statutory agencies. Patient care is compromised with an observable anhedonic affect at all levels. The book is a remarkable effort that is deemed to be an influential chapter in our understanding of addiction and its management. It is a voyage through philosophy, science and clinical practice a pure genius piece of work. It an essential reading for everyone working in the addiction field. It is guaranteed you will never think of addiction as you did before reading this monumental work.
Plessis, G.Du. (2017). An integral foundation for addiction treatment. Beyond the Biopsychosocial Model By Integral Publishers.
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