Tuesday, August 27, 2013

A Substance Abuse Counselor's Favorite Drug

We have all heard this before pertaining to Substance Abuse Counselors: The expectations are high but the pay is low, the paperwork is excessive and often torturous, the work itself is often frustrating and disappointing, and with high relapse rates it can easily be perceived as unrewarding especially when considering how many people that we try to help do not achieve the desired goals they set out for themselves. In addition, we have to get used to being lied to, tricked, scammed, manipulated, etc. None of this is new as it is well documented that working with those who abuse substances is quite challenging to say the least. 

For those unwavering counselors who stick with it year in and year out, why do we keep coming back to work every day? Once again, it certainly is not for the paycheck and it definitely isn’t for the glory or the recognition. What is it that draws us back in to work with this arduous population time and time again? 

The simple reason that many counselors keep moving forward and pressing onward in the substance abuse treatment field can be summed up in one word: Sincerity 

Sincerity is the virtue of one who speaks and acts truly about his or her own feelings, thoughts, and desires 

A dedicated substance abuse counselor will figuratively “dig” through mountains of broken promises, diversions, rationalizations, unfulfilled goals, and often sad outcomes associated with addiction in search of those treasurable moments when one of our clients honestly speaks their mind about something positive and we can sense that he or she really and truly means it from the heart. Some people refer to these moments in therapy as “Aha! Moments” or an “Epiphany” however in reality as counselors, we often have to hear plenty of meaningful-sounding statements from individuals whom we are helping that later turn out to be just empty talk. Every counselor can testify to the experience of having someone in a group, individual, or family therapy session seemingly having a “breakthrough” and saying all the right words, then afterward finding out that the same person who was spewing out all of that wisdom and insight was actually using all along and knew it was a matter of time before we would all find out. By contrast, true sincerity actually goes deeper than these unbridled “moments of clarity” that we may skeptically hope and believe we are witnessing. Experienced substance abuse counselors are too smart to get excited about statements like “I really know what I need to do now” or “I finally feel like I got this now!” or “I am not even thinking about getting high anymore!” because we have heard them too many times before to no avail. 

The sincerity that we substance abuse counselors truly crave is often expressed in a much a more subtle, honest and less demonstrative manner by our clients. A true sincere moment can occur when a young person in treatment who argued about the endless virtues and benefits associated with smoking an ounce of marijuana a day suddenly looks at us and says “you know, I miss smoking weed but I do feel a lot more clear-headed now that I stopped” or when someone we have been working with in session for weeks who repeatedly challenged everything we recommended finally says; “You know I have been working on what you suggested and I have to admit it actually is helping”. A sincere moment can be as simple as someone acknowledging the struggle they are facing in honest and realistic terms such as “This is a lot harder than I thought it was going to be” or “I know that I need to stop and I know what I should be doing but I am having trouble actually doing it” or “I am really glad that you did not give up on me”. As counselors, when it comes to witnessing moments of sincerity, we don’t even care if we get the credit. Rather, we appreciate that wonderful sense that someone we are working with is making a sincere effort to get better. For example, most counselors have had the experience of making a suggestion that we know is helpful a thousand different ways to a client with no impact then that same person hears the same thing from someone else and finally decides to try it. In that case we are just happy that the person took the positive suggestion no matter who or where it came from. We aren’t looking for credit or appreciation, we just crave the joy of being a spectator for those moments of sincere change no matter where it originated. The “high” experienced with sincerity feels good no matter how it comes about. 

So if you are a counselor reading this, then like a fisherman, keep on fishing in the sea of addiction patiently waiting for a nibble when someone expresses sincere change talk. Then keep on practicing skillfully reeling people in during those precious teachable sincere moments. You know it’s worth the wait, otherwise we would have all packed up and gone home by now.


Tuesday, August 20, 2013

Try Giving Out a Dose of This:

Has there ever been a harder time than now to be a young person struggling with a substance use issue? Drugs are everywhere and they are easy to find even when someone is not even looking. For whatever reason, the fear of the needle has subsided right along with the stigma of experimenting with heroin so there has been a huge influx of young people shooting dope all over, from the cities right on into the suburbs. As a result, most young people these days have known someone else in their extended social network who died of a heroin or other drug overdose or fatal drunk driving crash or other substance related tragedy.

Furthermore, in the current economy it’s tough for a young person who is trying to turn their lives around to get a job, especially with an arrest record for drug charges or other related criminal offenses. It’s even tougher in most areas for someone just starting out in life who has limited income to find affordable housing and quite often when affordable housing is found it is smack in the middle of a drug infested area often adds up to being just another relapse waiting to happen. These kids know that even if they stop using and they get on the right track, there are no guarantees of a successful career often because of a lack of opportunity. Young people who from the start chose to go to college are often themselves struggling so by comparison someone who went to jail for drug offenses or dropped out of high school because they were getting high may see little hope for making a reasonable honest living above and beyond minimum wage.

Sounds discouraging right? That’s because often it is for many young people trying to change and make up for their mistakes. Now imagine for a second a young person who is trying to get help starts hearing messages like these:

“At this point you should be happy you’re not dead!”

“Those people you are hanging out with are just going to bring you down along with them eventually”

“Jails, institutions, or death…that’s where this is all going to lead one day if you don’t stop”

“If you haven’t hit bottom yet, believe me, keep going the way you were and you will!”

“Sooner or later if you keep this up, the people who care about you are going to get tired of all of this give up on you and where will you be then?”

“I was young like you once and I thought I was smart too, but I’ll show you what happened to me!”

“You need to change that negative attitude soon or you are in for a rude awakening"

Surely, in many cases the above statements may be 100% true and many people will admit that they need a taste of reality in order to get motivated. It is absolutely important to start learning to think of the consequences. I am not trying to undermine that fact.

Nevertheless, these young people need more than just the wake up call associated with looking at the consequences and staring at reality. Those of us who are trying to help this generation of substance abusing young people must bring a crucial added ingredient to the mix. These kids have already had a pretty strong taste of reality and consequences along the way so they need something else if they really are going to change for the better and stick with it. As counselors, teachers, parents, and any others in a “helping" role, let us never forget the importance of handing out several daily "doses" of the powerful anti-drug of encouragement. Consider for a second, exactly what encouragement means:

Encourage -to inspire (someone) with the courage or confidence (to do something)
to stimulate (something or someone to do something) by approval or help; support

At the root of encouragement is:  courage - the quality of mind or spirit that enables a person to face difficulty, danger, pain, etc., without fear; bravery.

Encouragement therefore is all about inspiring courage in others.

The concept of encouragement can sound like it’s a huge deal but in reality, some of the best ways to dole out encouragement is by giving out subtle “doses” a little at a time. For someone who is struggling a “dose” of encouragement can be a simple as:

>A comforting pat on the shoulder or a welcoming handshake

>Providing a listening ear or a well-timed phone call

>Electing NOT to lecture someone after a setback or relapse

>Accepting and praising small incremental changes (baby steps) even when there is obviously still a long way to go.

>Saying just a few positive words or sending an inspiring text message or email

>Remembering to smile even when things might look bleak or appropriately using humor to diffuse a tense moment.

The consequences are always out there and it is important not to overlook them as we teach others to avoid them. However, just as important as the consequences, is being a reliable source of lifesaving encouragement. Did you remember to give out a few doses today?

Friday, August 9, 2013

Understanding the Disease - The Cold Facts

 A common way that people in the world of substance abuse have conceptualized addiction as a disease over the years, is to compare addiction to an established and accepted medical condition such as cancer. As the analogy goes, compared side by side, addiction is viewed as a disease the same way cancer is accepted as a disease because both Addiction and Cancer:
  • Have Diagnosable Symptoms
  • Are Progressive if not treated and therefore potentially Fatal
  • Are Chronic (long lasting)
  • Are influenced by Genetic Predisposition
  • Recovery is a process requiring lifestyle change
  • Relapse can be a major factor especially if proper self care does not take place.
This makes sense to most as the addiction-cancer analogy has been critical in explaining the rationale behind the Disease Concept of Addiction for decades. However, in my years of experience working with primarily less motivated people who are using/abusing substances, I have found that this analogy, although logical and reasonable, can still be extremely difficult to accept, particularly for young people. People in general, especially the younger generation, have an extremely hard time accepting the possibility that they may develop a condition that can be likened to something as ominous as cancer. (There are actually studies showing this to be true if you research the Optimism Bias). For example, have you ever tried to tell a drug abusing teenager that he has a disease? Get ready for an argument. If you are an adult in recovery, how would you have accepted early on, some counselor telling you that you have a disease? That conversation usually does not go very well. 

That is why I have evolved the way I open up a dialogue about the addiction-disease concept by instead comparing addiction to the common cold. The comparison between addiction and a "cold" as diseases still holds water similiar to the cancer analogy but there are some secondary benefits to using the cold analogy especially when considering young people and earlier stage users. For the most part, cancer is viewed as very "black and white" in that people generally view cancer as either you have it or you don't. In the addiction world, people often get unnecessarily hung up on the same black and white thinking- (Think of someone in a group pointing fingers saying "He has the disease, but that guy over there doesn't, and you have the disease too but you don't even realize it yet"). That kind of talk is rarely helpful and usually ends up more in debates and comparing rather than in insightful discussion. A cold on the other hand, is commonly viewed across a spectrum: A cold can start with the "sniffles" and if not cared for properly can progress all the way to deadly pneumonia. That simple reality makes it much easier for a younger person to grasp the possibility that if they keep going they way they are going with their substance use, than it could get worse with time. If someone abusing substances can at least grasp that possibility, then the door to a much more productive discussion is opened. 

I am not saying that this approach is going to open the eyes of all that hear it, or do anything miraculous like that. But still, it is a much better way to get people talking openly and with less defensiveness, and that in itself is an enormous step in the right direction. Try it.

Saturday, August 3, 2013

Would You Allow Your Doctor to Get Away with This?

I have been working in the field of substance abuse and mental health services for over 20 years as a direct counselor the entire time and additionally as a supervisor/trainer for the past 15. Just the other day, at the outpatient substance abuse clinic where I work, we were discussing a new client at our facility who was referred to our program after being discharged for a positive test for alcohol from another outpatient program. It turns out that this client is knowingly addicted to heroin but has not used heroin or other drugs in quite some time however he apparently was discharged from the other outpatient program for drinking alcohol. One of the newer counselor's jokingly asked me "What are we doing wrong?" in reference to the fact that at our program, we do not automatically discharge someone for a positive urine screen. My response was: "This situation illustrates what we are doing RIGHT -  We look at situations on a case by case basis as the change process for people is individualized and unique from person to person and situation to situation".

Suppose a morbidly obese man was seeing his doctor for treatment of his high cholesterol and he was making progress and slowly losing weight but one day came in to his doctor and confessed that he had a bad weekend and ate a big greasy double cheeseburger. Would the doctor simply look at him and say "You're not compliant, now go somewhere else!" Now suppose a diabetes patient told their doctor that he ate a banana split with extra whipped cream, would that doctor discharge him from the practice? In both cases, the doctor likely would do their best to first acknowledge the prior progress that had been made and then help their patient get back on the right track. Both clinically and logically speaking, continuing to help the patient is the wisest course of action for the doctor, few would disagree.  However, the substance abuse treatment field has been getting away with discharging people prematurely from treatment programs due to setbacks and relapses for decades. It is time this contradiction has ended.

Of course there does come a time when someone who relapses needs to be discharged. There often comes a point in treatment when someone is having repeated relapses or showing a persistent lack of effort or displaying a dangerous decrease in progress, when cutting the cord is without a doubt clinically indicated. However, most people need more than just a few chances to get better because change so often occurs incrementally or little by little with lots of ups and downs along the way. This fact cannot and should not be ignored by treatment providers. Think about your own situation and think about the last time your doctor recommended a lifestyle change for you (such as changing your diet, for example) Were you 100% compliant with your doctor's recommendations or did it take some time and patience to get it right? Did your doctor threaten to kick you out and stop seeing you right away if you failed to follow his recommendations? Should a diabetes patient get discharged over a banana split? Should a patient with high cholesterol be given his walking papers because of a double cheeseburger? By the same token should someone with a drug problem be automatically discharged just for using drugs?