C4 Professional Blog David Mee-Lee, M.D. October 5, 2007
There’s a lot of talk these days in the behavioral health field about recovery. In my opinion that is good because it puts an emphasis on helping people as they change their life, not just change their people, places or things. But what I don’t get is when counselors and other clinicians and treatment agencies say they believe that addiction is a chronic, relapsing illness but then tell clients on intake that if they use alcohol or some other drug, that they should not show up for group that day. Or if they do show up for group, the policy is to send the client away.
I have never heard of a program or clinician telling clients on intake about a policy that if they should get depressed or suicidal; manic or psychotic; panicky or anxious that they should not come to treatment that day. Nor could I imagine a program turning someone away because they showed up to a session with the very problem for which they are getting treatment. As William White puts it, they “punitively discharge clients for becoming symptomatic” (White, W (2005): “Recovery Management: What If We Really Believed that Addiction was a Chronic Disorder?” Great Lakes ATTC. www.glattc.org
What to do: First decide whether you really believe that addiction is often a chronic, relapsing illness just as that can be true for schizophrenic disorder, bipolar disorder, major depressive disorder and panic disorder. Then examine whether we still carry some of the stigma, discrimination and attitudes of the lay public that views addiction as willful misconduct for which there need to be consequences. It is hard to treat co-occurring disorders, if we have such different attitudes about mental disorders versus substance use disorders.
Then there are the clinicians who exclude an addiction client from group treatment if they have alcohol on their breath for fear of triggering other group members. The same clinicians are comfortable with a mental health client talking about domestic violence or sexual abuse even though that may trigger others in the group.
I have never heard of a therapist asking someone to leave group because their sobbing or severe anxiety triggered another group member and made them feel uncomfortable or even angry. I understand the need to keep the treatment milieu safe and therapeutic. And I am not saying that if a person is severely intoxicated with slurred speech and cognitively unable to participate that we should still try to do group or psychotherapy. There are more urgent needs to address just as an acutely suicidal and impulsive person will need safety to be first established. Nor am I saying that if the client is intent on using substances and trying to get others to use with them that we just ignore that and continue treatment as usual. But if a person is wanting help, what better place to be triggered than in a therapy group with trained therapists right there to help both the client who relapsed and any others who can identify with the same struggles and loss of control.
What to do: Make it clear to all clients that if they are seeking treatment for alcohol or other drug use and are trying to be abstinent or cut back, then recurrence of use is a treatment crisis. Just as recurrence of psychosis, mania, depression or suicidal thoughts and behavior are also crises that need professional assistance, recurrence of loss of control of substance use is a treatment issue. If a client is willing to reassess their treatment and change their treatment plan in a positive direction, then treatment continues.
Treatment is a process, not an event. Recovery works by attraction, not promotion. It’s hard to help someone if they are not there. Somehow, we’ve got to keep them coming back until your help is no longer helpful or needed in their recovery.
