There have been a lot of monumental challenges in the treatment of co-occurring substance use and mental health disorders. A client of mine in a residential treatment program for co-occurring disorders asked me the other day why I would want to work with this population; or for that matter, why would anyone? Even in his mind this field presents some difficult challenges. We could look at staffing, charting, counselor relapse, governmental and insurance changes, HIPPA compliance, state and county regulations, and many others. And in general, I want to look at five specific clinical challenges common among clients at every level of care.
Reluctance to Accept Help
Most clients, in fact most people, are not interested in making dramatic changes to their lifestyles. Instead of being changers, they become justifiers. We regularly encounter those who justify, minimize, deny, and rationalize their current substance use problems and the resulting consequences of addiction. So this is a challenge faced in every program and by every counselor. It is important to avoid arguing or forcing a client to accept treatment on the counselor’s terms. While I do not want the client to feel forced, ultimately I do want the client to accept treatment. In short, commanding, demanding, arguing, threatening, badgering, and coercing all result in increased resistance not acceptance.
Acceptance is the goal and there is an issue with partial acceptance; this is where there is acceptance with exceptions. “I will start treatment if…” Examples include: “if I can bring my phone, call my girlfriend ever hour, finish early, get the best room, come late, smoke whenever I need to, etc.” This is one of the reasons why I review common exceptions and excuses with clients; it seems to bring tremendous acknowledgement and admission. One of the other results is that it tends to increase personal acceptance and willingness to participate in treatment, which is one of my goals.
List of Common Exceptions
- Although I don’t drink anymore, I might have a glass of champagne at the wedding
- This is a special occasion
- I only drink on the weekend
- I couldn’t pass up free beer
- It’s a holiday
- It’s a special party
- I don’t drink anything, except beer
- I’m on vacation
- I just got a promotion
- It’s just for his graduation
- I just got a job and passed the drug screen
- She offered me a drink
- I’ve been really stressed lately
- It’s my honeymoon
- I only drink when I’m with the guys
- I never use except, when the pain gets really bad
- I only drink when I am traveling
List of Common Excuses
- One drink won’t hurt
- I know my limit
- Nobody’s perfect
- What would my friends think if I turned them down?
- I wasn’t going to quit forever
- I need some relief
- Don’t act so holy
- I’m not going to ruin their good time by not using
- I have really cut down on my drinking/using
- I used to have a problem
- I have been pushing pretty hard and I deserve a break
- Everybody drinks sometimes
- I was angry, frustrated, sad, lonely, or felt rejected
- Now is not a good time to stop
- I don’t use or drink like they do
- Hey, we’re all going to die of something
- No one is going to tell me how to live my life
- Screw it
- Beer isn’t alcohol and marijuana isn’t a drug
- I’ll handle it my way
- This is too hard for me
- Treatment is too costly
- As long as I don’t overdo it, I’m okay
- It’s not illegal to drink
- I can quit whenever I want
- Treatment is interfering with my work
- You drink, why can’t I?
- I just couldn’t take the pain
- I’m not hurting anyone
- I can’t get to sleep
Cognitive Processing Difficulties
Chronic drug and alcohol use and abuse can cause physiological and neurological damage. Furthermore, withdrawal effects, sleep deprivation, chemical imbalance, ADHD, anxiety, depression, traumatic experiences, thought disorders, nutritional deficiencies, detoxification complications, and increased stress levels all further compromise a client’s reasoning abilities. With these problems combined, it results in compromised intellectual functioning, reduced reasoning, and lowered processing ability. A client’s memory may be impaired and processing speed may be lowered. The ability to focus, concentrate, and sustain attention may be diminished. Abstract reasoning is more difficult for these clients requiring concrete and practical treatment materials. Judgment is often reduced which makes it difficult to link one’s choices with the consequences that inevitably follow. Furthermore, a client may have lowered insight into his mental health and substance use disorders and is therefore limited in the ability to seek the needed treatment. So the original problems cause complications that make it much more difficult to see the original problem and end up keeping the client stuck.
Living with chronic substance use and mental health disorders, not surprisingly, grinds away at hope and optimism. Clients entering treatment are often cynical, sarcastic, pessimistic, and hopeless; furthermore, they are not afraid to admit it out loud to almost anyone. This almost constant stream of negativity can flood a treatment environment; this is detrimental to both clients and staff alike. I encourage my clients to recognize negative thoughts, reject the negative thought, replace the negative thought with something realistic and positive, and then to rehearse the positive replacement often. Then, repeat this process as another negative thought, I’m sure, is on the way. Clients gain a sense of optimism, confidence, and improved self-esteem from this practice. It’s important, not just for me to be positive, but to train others to acquire and regularly apply this skill. Teaching clients the skill to change negative thinking into positive thinking has a very large impact on their ability to achieve long-term recovery.
Most clients are extremely motivated to do whatever it takes to stay sober, be healthier, and feel better; at least at first. However, as time in treatment goes on, motivation often plummets. Sometimes “I’ll do whatever it takes,” becomes “how little can I do and still get by?” In the beginning of treatment a client’s primary reasons for doing the hard work of recovery are held first and foremost in his or her mind. Clients mention the goals of raising their own children, getting married, staying out of jail or legal trouble, getting a job, and many other goals. The reality is that motivation levels may wax and wane. At times clients feel extremely motivated to stay on track, and at other times they are ambivalent, uncommitted, and even resistant. This is especially common in the second half of a treatment program, where the client may start to feel bored, superior, overly confident, tired, and disinterested. Our task is to encourage goal setting, teach character improvement skills, identify risk factors, and support progress without being judgmental, parental, or angry as this unfolds.
Even once a client has started down the road of recovery, strong desires to use again may still exist. Relapse is the return to using drugs or alcohol after a period of being drug free. Most people who struggle with addiction will have one or more relapses. Relapse potential must be managed with caution and vigilance. Past failings, difficulties, setbacks, and relapses form a monumental wall between the client and long-term recovery. Breaking down this wall is our challenge. Using this metaphor, each treatment, each recovery meeting, each jail sentence, each conversation with a counselor or sponsor is another hammer blow against the wall. Rather than seeing past efforts as failures because the wall didn’t yet fall, it is good to recognize that each subsequent blow moves the client closer to crumbling the wall permanently. Don’t give up; hit it again!
Facing the Challenge
The difficulties mentioned above are common for most clients moving through our treatment facilities. Don’t be afraid of these difficulties, but instead face them as the challenges they are. Our job is to provide help and support along their recovery journey. Many of our clients get better and lead long, productive lives. Some of them go on to help others and become the embodiment of hope. Clients survive and thrive because of the encouragement you provide. Thank you.
Recovery is a journey. Enjoy the ride!