The Question: To Rehabilitate or Habilitate?
Many years ago, when I was facilitating an intensive outpatient program for adults with addiction problems, one of the group members said something that at the time was funny to the group, but quite insightful and ingenious as it related to treatment and recovery. He said, “I have been in and out of treatment and have been to every program in this region, and just now seeing that I don’t know how to live and I am terrified!” This client went on to say that it often assumed that just because people look like grown-ups, that they know how to live. That somehow the drugs or alcohol curtailed functioning and the goal was to restore it. But, as he said and I quote, “I sit here and try to remember how to live, but there isn’t anything there. It is not that I am ignorant, but I never learned anything about how to manage life! Addicted people aren’t in need of rehab but we often need habbing! My addiction fills a gap and in a way it is my way of coping in the world. Sometimes I am aware that I am digging my heels into the ground, because I don’t know how to move forward and I’m scared.”
It is often assumed that adults know how to do things and are skilled enough to be effective in life and that somehow it was lost along the way and needs to be rehabbed to get that knowledge and skills back. This is not always the case. In therapy, much of the time, knowledge and skills are being taught and learned for the first time or in such a way that the recovering person (whether that be from addiction, depression, chronic pain, etc.) can learn and integrate new material in order to apply it to their lives in an effective manner. This, in turn, reduces their stress and confusion and ultimately eradicates relapse behavior. It may seem too basic, but not any less important. Sometimes the obvious is easily overlooked; we judge what we think we ought to know. However, life requires a lot of teaching and learning – since managing ourselves, relating to others, organizing, and problem-solving are not necessarily skills that are totally inborn. We learn them.
Going back to the group member, I think of this man at times and his complete honesty and candor. He was able to get beyond the human ego and self-examine in such an open way. He also made a lasting impression on the group and gave permission to others to be human and to accept human imperfection and fallibility. He also reminded me to be aware of the danger of assumptions and how they can negatively impact the delivery of quality treatment that is appropriately tailored to the individual.
Hence, rehabilitation is a process of rebuilding and taking a foundation and restoring it. Conversely, habilitation is development from the ground up – the putting into place for the first time. Although someone may be an adult and have points of strength – whether they are successful in business, popular with friends, a strong athlete – they may have significant skill gaps or other issues, medical or otherwise, which they have been subconsciously trying to compensate for or work around. This impacts the ability to manage themselves and their thoughts, emotions and behavior which negatively impact their ability to function and be effective in life. Hence, addictive behavior can be utilized as a coping strategy, although not a healthy one. Repeated use of substances can become habituated behavior and ultimately grow into an entrenched disease.
The Importance of Willingness
Our human will keeps us alive and kicking! It keeps us motivated and moving along. This is, as they say, a “good thing.” And, at the same time our will is generally tied to what we want or believe to be true – But, as we learn (hopefully), we are not always right. Human will is often over relied upon, especially when we are afraid and in need of summoning strength.
Change requires us to have a degree of openness and ability to tolerate discomfort. Discomfort can happen in our minds, bodies and emotions. When behaviors we have used to navigate and survive have been around a long time, we can be in store for a lot of discomfort when we try to change things. One of my clients once said, “I still get angry and it hurts in my brain. Although logically, I know I am just having old thoughts and the old ways don’t work, I have to ride out the frustration and the feeling of physical pressure in my head.”
Recovery requires a person to relearn how one thinks, emotes and behaves. This is the toughest work anyone will ever do! As one client recently relayed in a session, “I didn’t know that I needed to change my thinking, and that I was not appraising people and events accurately. Therefore my responses to things that happen are often not productive and tend to cause problems for me, including relapse with alcohol.” She was also struck by her need to habilitate vs. rehabilitate, because she did not have the opportunity to learn the skills she needed to manage what was presenting in her life in an effective way. Her appraisal / way of conceptualizing the problems which presented were inaccurate. Therefore, the appropriate solutions could not be identified. The mechanism of how to think productively needed to be put into place, as her upbringing did not model a comprehensive enough reality upon which to build.
Therapy as a form of Mentoring
Unfortunately, psychotherapy continues to carry a stigma of being sick or having something wrong. One of my clients once said to me, “I like coming to therapy, but I don’t want to be sick!” I replied that she didn’t need to be sick to come to therapy to further develop herself and that therapy can be framed in a number of ways – including counseling, coaching, or mentoring dependent on the circumstance. When we really think about it, many of the structures that were once in place to help people learn to be effective in life have waned – men used to work side-by-side and the older men taught the younger men how to work, as well as be in the world. Older women taught younger women skills and shared stories about what they learned along the way – hopes and dreams and reflections on what was important. There were apprenticeships and civic endeavors which were more inclusive. People used to visit one another, gather, and talk more – exchange ideas and expand themselves as a result of social exchange. We don’t do that as much. Life has become more insular.
Therapy is based on a sacred trust between the therapist and client. It is a form of mentoring. The therapist collaborates with the client in co-exploring new ways of living which could be more effective and positive. And, according to tradition the mentor does embody a leadership role pointing to opportunities for education, practice, and integrating learning in order to develop mastery and wisdom. That’s therapy teaching, learning, practice… practice… practice. Through this process we learn the ingredients of a more productive life and new ways of being happy and contented. Being able to accept and participate in mentoring is necessary to be successful in recovery (from whatever!) and life in general.