SA Tx, Clinical Treatment Practices in Substance Abuse: Prospecting Solutions Through a River of Denial -Brandon Dellario LMSW LASAC

"In the film, 'Mad Max, Beyond Thunderdome,' Mel Gibson finishes a steel cage match by taking down a killer named Blaster.  When Blaster is defeated on the dirt, Gibson rips off his helmet and reveals the notorious Blaster to be a sweet, smiling little boy.  Blaster’s keeper, Master, was using him as a tool to rule and destroy.  Maybe Master is similar to the disease of addiction, and Blaster likening our own true-self, a child hiding deep inside." prose selection by Brandon Bruce Dellario

     As a treatment practitioner and peer in the mental health system, being a peer professional may be advantageous in helping clients.  It can also have its’ barriers.  Peers have a way of relating and communicating hope with one another which is fundamental to a recovery process.   People feel more included when they know others are in it together with them.  I am a proud member of our community as a peer, and blessed to speak of it as a professional.  Although, because of the various people I come into contact with, it is especially important for me to work and live with great professional integrity regarding boundaries. 

     The following is my experience in working with those commonly labeled “low-motivated” or “resistant” clients.  Although clients are often called names such as, ‘problematic,' we as practitioners know there is no such thing as an untreatable client or condition, only improper practices or treatment modalities.  While clients do not always follow up on the demanding though agreed upon commitments of a treatment plan, this is not our responsibility.  We the professionals are the party responsible for seeking out solutions.  So what are professionals able to do regarding a client who presents an, "insufficient instigation to change?" 

“Lack of motivation for change or motivational ambivalence is widely regarded as a primary obstacle in treating substance abuse and dependence and is related to the high rate of treatment dropout.  The substance abuser experiences insufficient instigation to change, and makes little or no correction in changing his or her substance-abusing behavior despite adverse consequences of continued substance abuse.”(Emmelkamp, 2006 pg. 43)

     In the beginning of my experience as a peer professional, I worked only with individuals who came to groups regularly and actively participated in their own recovery process.  Two years later, I began recovery coaching as a peer support specialist in substance abuse treatment and providing resource information to clients of a treatment facility.  I loved the job and planned to go on in the field, but I was faced with some new challenges.  There were those who were very resistant to, or displeased with the treatment services being offered them. 

     Starting work at the treatment facility, I had some useful information from 12 step programs, my education and employment trainings.  I put these tools to use when working with people who (for whatever reasons) did not want to hear what the professionals had to say, nor anything related to the topic of ‘recovery.’  I began to back off when appropriate. I asked them to tell me their own goals, supports, barriers and ideas about aftercare.  Still, I grew further confused about giving a “resistant” client a safe, comfortable atmosphere, while attempting the sorely-needed confrontational styles of counseling in a chaotic group setting. 

     Focusing on the clients’ needs in appropriate self-disclosure, I began asking clients for permission to share some of my own experience.  Peer Support Specialist positions are especially conductive to this type of dialogue, though every clinician has struggles or victories they can use in relating to clients.  Everyone is a peer in some way or another.  Some of these similarities may be fitting to vocalize sparingly with clients for various reasons.  Practitioners can share a bit of themselves while focused on the wellbeing of clients, in careful recognition of radical differences which may exist.   
     After all, we each have our own idiosyncratic paths in life.  In 12 step programs they say, “What works for you might not work for me,” in distinguishing this truism.  As the old saying goes, you don’t know what it’s like to be someone else until you’ve walked a mile in their moccasins.  In summation, we may only seek to understand what another person’s life is like, while observing a relationship to anyone as simply another human being, not un-like ourselves.  We are all equals in what my sponsor calls our larger "human family." Everyone is someone's brother or mother or daughter and so on.  At times, I think of myself as any person's spiritual sibling on a strictly human-level.

     Mental health professionals are not here to tell others what to do.  I am not sponsoring clients, nor am I to be in any kind of intimate relationship with them.  I stay accountable to my supervisor in spotting potential difficulties in this area.  Yet, clients get very personal, sharing the honest details of their lives in groups and one-on-one with professionals.  This can easily draw a professional into an empathetic relationship with the client, and become frustrating when a client will not acknowledge behaviors which appear unhealthy.  Whether it is a refusal to change or addiction protecting itself with denial, recovery decisions are ultimately the client’s choice.  Practitioners merely do the next right thing to support and encourage them by providing an environment for change.  Consequentially, the clinician’s role in a person’s life is an awesome responsibility with no picture perfect answers.

     I do often find it challenging to work with those who would rather not be there.  Some of the people we serve get drunk and high right before we see them which make it especially hard to conduct sessions.  With these people we do what we can.  It may be allowing a client the opportunity to do certain things for themselves.  Answers may come from asking questions about client behavioral consequences.  In my professional practice, I seek to steer clear of personal enabling or actions of co-dependence.  For other practitioners, it’s a challenge to simply remain open-minded in supporting a client who seems bent on self-destruction.  In this situation we remember it is our job treat whatever mental health conditions are presented, regardless of our opinions on a clients persona or personal choices.

     Whatever the case, we can help even those who don’t even want help with suitable models of therapy.  Betty Ford is famous for popularizing this idea.  Though some clients may need to exhaust their resources or suffer devastating consequences before gaining abilities to see what is happening in their life, let alone ask for help.  I was once lost in the woods myself, and no matter how lost someone might seem, there is always hope.  There have been single weeks where I’ve seen people go from a huge resistance to change, to a gigantic surrender to a program of treatment and recovery.

     It’s good for me to remember this, that although someone may be resistant to help, it doesn’t mean we cannot help them.  I have been taught great, simple techniques for helping people find their own inner wisdom.  These are the motivational interviewing and peer support practices of asking the client honest, open-ended questions.  These questions are best asked without a motive of leading the client to a certain conclusion.  My motivations as a professional are not always best for the client.  Sometimes I look for things like goals, barriers and supports and ask questions about them, but most of the time, people just like someone to talk to and listen to them.  At other times I have found it useful to employ a didactic or assessment instrument to grease the conversational wheels. 

     I am always learning more about when to bite my tongue and attentively listen to the people I serve.  This is called “Active Listening.”  I have been trained to wait 3 seconds after someone speaks to respond, this insures that they are done speaking and ready to listen to my response.  I can look for and point out strengths, without co-signing poor decisions practice unconditional acceptance of all behaviors, or just be there (which is all people need sometimes).

  These are especially helpful when a client is resistant.  For instance, if a client were to tell me that she thinks, “recovery sucks,” I can open-mindedly ask her questions about her views without judging them as ‘right or wrong.’  Or I could say, “You have a very strong character, don’t you?” “You know, you’re right, I bet there are many big challenges for anyone in recovery” or, “I admire your honesty, thanks for sharing your opinion!”  These example techniques of Motivational Interviewing called Rolling with Resistance.  My way of following this technique is to think of the client as a friend, while responding as such (but with professional practices and boundaries).  We can always relate to someone on a human level, regardless of how different we may be.  I work on giving clients the benefit of the doubt in relation to their own perspectives of circumstances.  People are their own greatest authority.  If there is something they are lacking or could do better with, I must also recognize that what they are currently doing is working for them in some way or another, for reasons I may not be aware of.  In any situation, there may be present behaviors or circumstances which help the client in their recovery.  I ask them about their own concerns, and express those concerns back to them using reflective statements.

     Sometimes I work with people in dual diagnosis recovery, recovering from co-occuring substance abuse and mental health conditions.  Although there can be a world of difference between individual clients in dual recovery, these are yet additional factors to consider when working with people in recovery.  In substance abuse treatment it is especially important to look at each client individually considering there are a variety of problems facing each client in various environments.  For dual recovering clients, struggles may include these general reoccurring problems, “. . . low self-efficacy, primary negative symptoms of severe mental health problems, such as loss of motivation, energy and drive, apathy and difficulty in experiencing interest or pleasure, and secondary negative symptoms, such as depression and the side effects of medications.”(Graham, 2004 pg. 9)  Further individualized factors to consider when working with clients are age, sex, sexuality, gender, financial, legal, physical, religious and cultural differences which must be taken into account when appropriate.  Empathy and open-mindedness to possible solutions are readily at hand when professionals remain aware of these diversities.  Motivational Interviewing has proved to be a valuable technique in behavioral interventions for those with dual diagnosis.(Barbaro, 2007 pg. 26)

     “Social workers must be concerned with his or her own values, and control for inappropriate intrusion into practice situations.  This is known as Value Suspension.”(Barlow, 2009 CD-ROM)  It is important for me to keep my own opinions to myself when working with someone.  We all have different perspectives from living out our own experiences.  Telling someone else what to do, or talking about something I have no training or personal experience with is counterintuitive.  Normally, very few situations call for sharing my personal ideas with someone I am helping.  I can appropriately self-disclose some personal experience, share some psychoeducation or maybe even make a suggestion.  However, as a mental health professional, my focus should be on supporting the client in their own personal path of recovery which will take whatever direction that they, the client choose. 

     Asking someone open-ended questions will guide them to understand themselves and find what they want to get out of recovery.  This is what is most important.  Personally, It has been some work in getting myself out of the equation in practicing this ethical principle.  I struggle at times and have a long way to go with practicing selflessness in service to anyone in need.  Although more and more often I find myself listening to what clients have to say while attempting to understand. In following some rhetorical colloquialisms, I cannot ‘walk in someone else’s shoes,’ but I can ‘put myself in their shoes.’ 

“The simplest and most straightforward form of treatment is to screen patients for tobacco, alcohol and other drug use and to counsel those in whom you believe this is a problem.  This generally takes the form of giving advice on the health effects of the drug, assessing the patient’s readiness for change, and providing information and assistance on treatment options.”(Rastegar, 2005 pg. 27)

    

     An important streamlined-statement on interventions, making assessment and psychoeducation sound like the go-to models of treatment.  However, notice the language in this treatment recommendation, ‘. . . counsel those in whom you believe this is a problem . . . the patient’s readiness for change, and providing information and assistance on treatment options.’  This sounds like treatment is more about attending to the needs of the patient and less like pushing people into what I want them to do.  Now, I don’t have to agree with something I think may be problematic for clients.  In fact, I have a responsibility to be honest about treatment and whatever information I have.  Though I don’t want to direct energy into commanding others to perform, or make it sound like there is only one way to recover. 

     Although most people who suffer with substance abuse disorders eventually find great value in a program of recovery.  There are occationally clients I work with who seem able to stop using drugs on their own.  There are those who have the capability to remain abstinant for years without aftercare, outpatient treatment, long-term maintainance, mutual-help groups, relapse-prevention programs or treatment of any kind.  I can’t tell who those people are, and even if I could, it’s not my place to tell anyone else if they are or are not an addict/alcoholic.  This identification is strictly up to the client to make such a determination.  Professionals can point out probable or actual consequences of a client’s behavior.  Some use testing instruments to measure the possibility of a substance use disorder, then present evidence to a client.  If clients identify with abusing substances, they can use the resources provided for treatment.  Even if they don’t identify themselves as having problematic behaviors, they can still use resources provided toward a new way of life however they choose.

     There are many different treatment techniques that substance abuse counselors use with clients.  Most use a combination of various treatment approaches involving 12-step, cognitive behavioral, motivational enhancement, therapeutic community, or psychodynamic.  One method that has been found ineffective in evidence-based treatment is the delicate practice of Confrontation.  “. . . It results in resistance and treatment dropout . . . [but] there is still a widely held belief among counselors that client denial must be ‘broken down’ for treatment to work.”(Elliason, 2007 pg. 16) 

     I know that it’s not up to me to ‘convince’ someone they have a problem, or break denial that I feel may be present.  I am personally a peer in addiction recovery.  Drinking and drugging was my only solution to the confusion.  Little did I know that it was also my greatest source of it.  I held onto drinking and drugs with a death grip.  I had periods of clean time during those 12 years of regular use, but I never saw a real way out until I opened up to a therapist about my drug problem.  He followed a simple substance abuse assessment, asking me about every single year of my drug use, and other life difficulties I was experiencing at the time.  He left it up to me to put the pieces of the puzzle together.  I did!  At first I got very frustrated, then called my friend to pick me up for a mutual help meeting the next day.  Thank God for that counselor’s educated treatment methods.  He gave me the opportunity and room to look at what I was doing to myself for the first time ever. 

     It seems that many styles of Confrontation can work to aggravate someone’s refusal or denial, fueling them with justification, possibly causing them to retreat further into rationalization.  Some people know they have a problem, but continue to drink and use drugs.  Some have tried to stop so many times on their own and failed, they may believe it’s impossible to stop.  This situation is a great chance for me to tell my story.  I let them know I have been clean for years, and if the past millions of recovering people can do it, they can too.  It’s not always appropriate for me to tell my story or share my personal experience, I spend time weighing the positives and negatives of sharing before I do.  Firstly, I focus on the client’s needs to see what will best suit them at the time.  Secondly, I can postulate on whether or not they would be open-minded to my self-disclosure.  Then, if they do seem to want inspirational words about something outside their own life, I can ask permission to share my experience on the subject.  I also like to make it clear that none of us knows everything in recovery.  We each have our own path and a personal mentor/sponsor is the best person to ask for the final word on any subject.

     Many people in recovery don’t name specific drinks and drugs they used in the past, others do name them for identification purposes.  In fact, sometimes substances themselves may not be discussed at all throughout an entire group meeting.  I sometimes bring this, 'no-substance-label,' philosophy into my work as a recovery coach because it displays that we are not fighting a substance, but a disease inside us.  Normally people in society do know various drugs to be different and have different effects, but for myself they all go to the same place starting with the first.  As an addict and alcoholic, all drinks and drugs put me on a downward spiral of destruction.  One of anything will take me to unhealthy places I never want to go again.  
     At times, I simply inform clients on the devastating effects of prolonged drinking, drug use and lifestyle issues.  I do this in hopes they will stop the progression of their own unhealthy behaviors by beginning a program of recovery.  As treatment practitioners we have only to focus on doing the next right thing, making a good decision as best we can, the rest works out for itself.

    

    

References

Barbaro, G., Nava, F., Barbarini, G., Lucchini, A. (2007). Management of Medical Disorders Associated with Drug Abuse and Addiction, Nova Science Publishers, Inc., New  York, NY.

Barlow, D.H. & Durand, V.M. (2009). Abnormal Psychology: An Integrative Approach (CD-ROM). Belmont, CA: Wadsworth Cengage Learning.

Eliason, M.J. (2007). IMPROVING SUBSTANCE ABUSE TREATMENT, An Introduction to the Evidence-Based Practice Movement, Sage Publications Inc., Thousand Oaks, CA.

Emmelkamp, P.M.G. (2006). Evidence-Based Treatment for Alcohol and Drug Abuse, Routledge, New York, NY.

Graham, H.L., (2004). Cognitive-Behavioral Integrative Treatment (C-BIT), John Wiley & Sons Ltd., West Sussex, England.

Inaba, D., Cohen, W. E., (2007). Uppers, Downers and All Arounders, CNS Productions Inc., Medford, OR.

Rastegar, D.A. (2005). Addiction Medicine: An Evidence-Based Handbook, Lippincott Williams & Wilkins, Philadelphia, PA.

McKinney, R. (2009). SWRK 6330: Advanced Seminar in Culture, Ethnicity, and Institutional Inequality in Social Work Practice. Western Michigan University, Spring Semester, 4422 CHHS, W 2-4:30.