The Space Between Stimulus and Response

Reflections on addictions counseling and creating change


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Addiction, treatment and pregnancy

Working with clients who are also pregnant is challenging for several reasons. First, we must consider damage to our clients and to their unborn children. Second, we may need to cope with unpleasant countertransference if we believe our clients are doing damage to their unborn children. Third, pregnant clients need to be admitted for services within 24-hours, if an agency in Maryland is to receive public grant-funding. Ethically, pregnant clients cannot be discharged for non-compliance, without consultation of the state, potentially making it more complicated for us as clinicians to enforce treatment structure and agency policies.

I share supervision sessions with a friend and co-worker. I don’t think she would mind if I shared. She recently conceived after trying for many months, and was having difficult countertransference in relation to a young pregnant client. It had been difficult for her to reframe this client’s use, as she saw it as insensitive, neglectful and uncaring toward the unborn child. She found herself judging, and having expectations that, like her, every woman should take great care of her health during pregnancy. It was also difficult for her to reconcile why it was difficult for her to conceive, while it was not for her client. We spent time a lot of time in supervision trying to make sense of these issues, assessing her obligations at a clinician, and also trying to find ways she could let go of dynamics not within her control. I shared all of her feelings, though perhaps not with the same intensity. In the end, my friend called on her empathy. She said, “How would I feel if my character was being judged during my most difficult days?” My co-worker demonstrated strength and ethics by identifying her bias, by sharing it in supervision, and by actively working to correct for it.

As substance abuse clinicians we have the obligation to inform clients on the ways substance abuse can affect their pregnancies and children. The Substance Abuse and Mental Health Administration (SAMHSA) explains that continued substance abuse during pregnancy is a major risk factor for fetal distress, developmental abnormalities and negative birth effects. We may also need to take extra care in connecting our pregnant clients to prenatal care services, as SAMHSA notes that clients may delay prenatal care, fearing legal consequences. Clients should know how risks to their unborn children can be reduced by seeking prenatal care early. In conjunction with a physician, it may also be important to discuss how opioid-maintenance therapies may do less harm than sporadic misuse, and that continued use of some psychiatric medication may be preferable to the damage done to unborn children through maternal stress hormone. It may also be helpful to explain that there are many clients who receive substance abuse treatment while pregnant and that there are many programs specifically for clients who are pregnant (e.g., The Center for Addiction and Pregnancy at Hopkins Bayview). It may be helpful to explain that parents are rarely charged due to substance use and pregnancy, though there is a real risk of Child Protective Services (CPS) involvement, especially if a child is born drug-dependent. Clients may also need to know that an open CPS case does not mean losing parental rights. We may also need to provide clear explanations of our obligation to report to CPS in cases of child abuse or neglect. (Indeed, my co-worker did call CPS, due to her client’s ongoing recklessness and high-risk use while pregnant.)

We may also need to be prepared to educate clients on their options including temporary custody, open- and closed-adoption and abortion, without conveying bias. We may have greater rapport and influence if we utilize a gentle empathic style that takes into consideration the additional stress, demands and guilt that may arise for women who are using and pregnant. Using motivational interviewing, the motivation that may arise from maintaining custody of a healthy child can be a foundation on which treatment is built.


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“Learning would be exceedingly laborious, not to mention hazardous, if people had to rely solely on the effects of their own actions to inform them what to do. Fortunately, most human behavior is learned observationally through modeling: from observing others one forms an idea of how new behaviors are performed, and on later occasions this coded information serves as a guide for action.” -Albert Bandura, Social Learning Theory, 1977

         I grew up in a household where I witnessed very little substance use— my mother did not smoke cigarettes, drink alcohol or use any other illicit or prescribed substances. I suppose I learned about alcohol and other drugs through D.A.R.E in elementary school, and at that time I thought they were dangerous. My brother, 7 years older, was a recreational user of marijuana and alcohol, and he smoked cigarettes in his teens through mid adulthood. At a young age, I recall “ratting” him out to my mom for having marijuana (found while snooping in his room)… He gave me my first beer as a young teenager. I drank it eagerly, impressed that he would include me in a custom he shared with his friends, though it left the room spinning. As a teenager, I can recall wanting to have the pleasurable altered state of consciousness achieved through substance use. I cannot recall how I heard about these effects. I recall the desire to rebel and to have the experience of being intoxicated more than the desire to fit in with peers. In fact, I had friends that never used any mind-altering substances. I experimented a little, but always feared losing control or jeopardizing my health. These fears deterred me from experimenting with most substances. This interests me because many of my clients coping with substance use report debilitating anxiety, and yet it is not the sort that stops them from taking risks with respect to their use.

         My view of substance abuse is somewhat different now. I still understand wanting the experiences of drug experimentation, and I do not have a problem with people who choose to use safely in moderation (not everyone can do this, of course). And actually I sometimes wish I had experimented a little more, so I could relate better to my clients. But fundamentally I realize I don’t need to have matched their highs to understand them. We relate instead through shared feelings and shared human experiences, which for them underlie use.

         I take substance use more seriously now. In my work, I have witnessed substances do harm to so many people; use has cost them jobs, homes, friends, family, and their lives. Being confronted with the risks of use daily makes the idea of using and witnessing others use less entertaining. I realize now that many people will use in college or high school, just like their peers, and yet their peers will stop experimenting, stop partying, and these individuals will go on to ruin their lives through use. Many people do not know how they are predisposed to use through learning and genetics, until they are hooked. Even “experimentation” is risky for those who are predisposed. With the exception of occasional instances when I have been surprised by the risks my clients have taken to use, I have never encountered an instance where I have judged my clients for making the choices I did not make. I believe everyone has their own path, there own tasks to learn, and I recognize that I have made many mistakes and not always lived well, despite not having developed a debilitating addiction.

         I also truly believe, and always have, that people can live rich lives without any mood-altering substances. Other than school drug education, no one close to me ever advised me about use or pressured me into using. Yet I think advisement can be subtle; people in my family modeled that we could feel feelings safely and that we did need substances to cope, and my social circle modeled that people can enjoy themselves without using. And for these influences I am grateful.


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Too much stress, and the overuse of self-control resources

In the last few years, I found myself working with an addictions counselor who was very vocal and direct. I was new to the field, yet I felt strongly that her approaches were not always therapeutic, and sometimes not professional— too much self-disclosure or inappropriate topics under discussion. During our group, I allowed the clinician in me to be swallowed up by her dominating presence. I felt at a loss for how to redirect the group, and I stayed quiet because I worried that I would be even less effective. I would come out of group seething, but felt helpless to do anything. I was crippled by self-doubt. During this time, my self-efficacy as a new clinician plummeted, making work I used to feel somewhat comfortable with even harder. I felt down and ineffective, and I dreaded going into work. I felt tired, and slept more though it never felt like enough. (I have learned that I experience stress physically first, meaning I may feel exhausted and sick before I can tell that I feel overwhelmed emotionally and cognitively.)

I coped ineffectively by blaming my co-clinician, instead of acknowledging how frustrated I was with myself for not interjecting more in group or suggesting that we facilitate groups individually, alternating hours. I stood still, treading water, instead of taking action to get additional supervision or wisdom about the situation, instead of taking additional time to plan topics for group so that I would have a clearer way to contribute. Due to fatigue, I also let basics of self-care go, eating less nutritiously, exercising less, engaging with my own interests less. It was a difficult time. The difficult thing about depressive symptoms is that you do indeed feel down, but then you also self-select behaviors that are detrimental to your sense of self and your mood. Of course, interventions such as behavioral activation are built on this principle.

Now I believe I would handle this situation differently. I have better supervision in place, I would re-involve myself more regularly with my own therapy, and I might consider psych medication to help with my mood. I also have a little more willingness now to take risks in the group treatment setting in which I work. I am more comfortable working with my group without a co-facilitator. Now I don’t always wait for anxiety to pass before trying out a skill or teaching something new. What I do is not always perfect, but I make myself ACT anyway because this is how I learn, because it is my job to model tolerance of discomfort, and because my job demands that I be proactive.


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Grant me the serenity to accept the things I cannot change, The courage to change the things I can, And wisdom to know the difference.

 

As we all do, I have certain values that are near and dear to me. I am pretty conscientious and I value accepting responsibility for my own behaviors and choices, and the Serenity Prayer (adopted by Alcoholics Anonymous) embodies this ideal. I also believe strongly in “live and let live,” meaning I try to accept the choices and traits of other people. Everyone has her own journey. In every situation, every conflict that affects me, I have a role. And if I can see my role, then I empowered. If I choose to blame others, then I relinquish my own power. The courage to change the things I can also has a lot of meaning to me, as I am only recently getting to a point in my life where I can take risks, even in the face of anxiety, and be proactive.

Continued to take personal inventory and when we were wrong promptly admitted it. As in Step Ten, I value the idea of taking a daily inventory. Did I live today according to the traits I value? According to what keeps me healthy and well? If not, how can I make it different tomorrow?

I have been taught through graduate school to seek out evidenced-based treatment, and though there has been little research to ascertain which elements of 12-step programs are effective, research indicates that involvement in a 12-step program seems to enhance treatment outcomes among those abusing alcohol and other substances (Emrick et al., 1993 in Capuzzi & Stauffer, 2012). Social support is a protective factor that underlies resiliency and psychological health. Addiction narrows people’s lives, such that interests and relationships not associated with use are given up. Individuals who have been using for some time often forget what they did and what they were like before use. Twelve-step programs assist individuals in developing new networks of support and new social outlets with people who will respect abstinence and who will understand the struggles of being in recovery.

I also understand that working through the 12-steps can facilitate self-growth and self-understanding. A client of mine recently said at her one-year anniversary that addiction was not simply in her alcohol and drug use, but rather in her attitude, her behaviors and her lifestyle. Recovery is about crafting a sustainable lifestyle that makes use less possible and less desirable. The twelve steps may help make individuals aware of patterns of relating to themselves and others that are unhelpful (e.g., harboring resentment). They may assist individuals in shifting their attitudes and taking personal responsibility. There are also other self-help programs that can facilitate such learning that are not based on the 12-Steps. I have very positive sentiments about Smart Recovery. Smart recovery offers group support and implements a curriculum focused on clarifying values and principles of REBT/CBT.


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Behavioral- and pharmaco-therapies combined create the best outcomes

I strongly support the use of pharmacotherapy in the treatment of addictions. In fact, SAMHSA documents “research shows that when treating substance-use disorders, a combination of medication and behavioral therapies is most successful (http://www.dpt.samhsa.gov/patients/mat.aspx) .”

To address the use of specific pharmacotherapies, there have been multiple research studies demonstrating methadone as more effective than non-ORT therapies for patient retention in treatment and for suppressing opioid use and demonstrating buprenorphine as significantly better than placebos for the suppression of opioid use and equally effective as methadone. Campral and naltrexone have also shown efficacy in promoting abstinence and in reducing heavy-drinking, respectively. These medications are not doing the work of recovery for clients, but they may give clients a slight edge, a pause if you will, during which they can think of consequences of old behaviors, use other craving- and thought-stopping techniques, and actually make new healthier lifestyle choices.

Neurologically speaking, it is understood that the frontal lobe system that inhibits risky behavior and weighs consequences to make decisions does not get to weigh in as it should when a person with addiction is triggered and driven by the pleasure pathway. Further, addiction depletes the brain of natural flowing feel good chemicals including dopamine, endorphins, serotonin and norepinephrine which can create a general lack of motivation and anhedonia in clients who are vulnerable and in early recovery. In my mind, carefully monitored pharmacotherapies help clients pursue treatment on a more level playing field, when the addicted brain would otherwise keep the decks stacked against them. Some will say that combating substance use with the use of other substances perpetuates the problem, but effective medications in the treatment of addiction typically allow individuals to function more normally, without pleasurable and problematic intoxication.

Of course, effective responsible use of pharmacotherapy should include a plan for eventual taper; it should include knowledge of evidence-based best practices; and it should take into consideration the risks of cross-tolerance/substitution and pharmacological interaction. For example, opioid replacement therapies (methadone or buprenorphine) can be contraindicated with the use of other sedating medications, like benzodiazepines, or in cases where a client continues to abuse depressants such as alcohol, because together they can increase the risk of respiratory depression and fatality.

I suppose pharmacotherapy for addiction might also encompass use of psychiatric medication for addressing comorbid issues such as hallucinations, delusions, depression, mania, anxiety,  inattention, impulsivity or hyperactivity. Our text (Capuzzi & Stauffer, 2012) points out that client with co-occurring psychiatric problems often have poorer treatment retention and poorer treatment outcomes. Appropriate psychiatric medication maintenance may improve treatment outcomes in these clients. It may also enable these clients to cope with other issues often present with co-morbidity, including inadequate social support, unstable relationships, insufficient housing and unemployment (as listed by Capuzzi & Stauffer, 2012). Again, treatment providers must ethically stay current on evidence-based practice. They must be mindful of which medications have greater potential for abuse. For instance, stimulant and sedative/hypnotic medications have fast-acting effects and high potential for abuse. Treatment providers must also be mindful of the fact that changes in the addicted brain may not represent symptoms of a client at baseline. Clinicians must be careful of making labeling and potentially stigmatizing psychiatric diagnoses while a client is in early recovery. Symptoms of withdrawal and post-acute withdrawal can often masquerade as symptoms of mood disorder. I believe clients should be assessed and then reassessed once well-established in recovery.

Capuzzi, D. & Stauffer, M.D. (2012). Foundations of addiction counseling (2nd ed.). Upper Saddle River, NJ: Pearson Education, Inc.


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“The biggest deficit that we have in our society and in the world right now is an empathy deficit. We are in great need of people being able to stand in somebody else’s shoes and see the world through their eyes.” — Barack Obama

I am not sure I have ever experienced self-righteousness in relation to clients. I am more tempted to say that I have gratitude from my experiences with clients. I am often aware that my clients have survived many trials and tribulations that I have not had to endure in my own life. And as I have said, having been adopted, I feel strongly that my life could have taken a very different turn if my environment had too been different. I like to highlight that my clients are survivors and to emphasize the way they have coped successfully in the past, or to generate compassion by emphasizing how now dysfunctional behavior once served a purpose for clients while growing up. I feel very strongly about what Professor McWay said in our last lecture, which was to have appreciation for how very difficult it can be to change, even for individuals (like graduate students) who are largely able and who may have a strong support network.

Staying in contact with my inner client means that I continue to be on a path toward self-discovery and self-growth. It means that I continue my own therapy and supervision. It means that I do my best to model for clients effective behavior and the honest struggles to achieve personal effectiveness.

One thing that has helped me is to recognize my underlying feelings when I encounter irritation or frustration in relation to a client. I often find that there is a fundamental doubt about my effectiveness as a counselor. Am I doing the best for this client? Do I have a sense of how to support a client in dealing with her issues? The truth is that sometimes it is easier to see clients as difficult, rather than to admit that you are stumped about to proceed. At other times, frustration may indicate that I have overstepped my boundaries as a clinician; for example, having done all the referral paperwork myself for a client seeking inpatient treatment. I am learning how important it is to honor my emotions (and their appropriate expression) and to use them as cues about what is or is not working in my life.

Using appropriate self-disclosure, I also reflect on times I have dealt with mental health issues of my own— disordered eating, depression, anxiety, and perfectionism. I find that people have certain universal experiences. We have all felt sadness and loss, fear, joy, anger, guilt and shame, even if our situations are very different. I make efforts to tap into times when I have shared the same emotions as my clients. Further, all people have similar needs— including belonging, safety and meaning. I try to tap into times when have successfully and unsuccessfully tried to meet these needs. And when in doubt, I try to humble myself and to simply listen.

 


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“One cannot brave the vigors of loneliness and desperation of such inward journeys without a companion.” – Rollo May

I am perhaps more comfortable with cognitive-behavioral therapies because these were emphasized in my graduate program. However, I do strongly agree that our responses to our circumstances can create more suffering than our circumstances themselves. There is a parallel concept (Buddhist in origin) in meditation and mindfulness work— the two arrows of suffering. When misfortune happens, two arrows fly. The first arrow is our actual pain over the circumstances that are unavoidable, but the second arrow is self-inflicted emotional pain, resistance and judgment.

I also find that the A-B-C model of CBT is very accessible, and it can help clients to identify their role in a bad situation, and it can help clients understand why they respond in intense and sometimes problematic ways. Identifying our thoughts is also the foundation of implementing positive self-talk for coping. I also appreciate that CBT emphasizes positive behavioral change as an effective means of changing outlook or perspective, as it can be very difficult to change thinking styles. “Train the body and the mind will follow.”

I also try to draw from existential therapy, which I find very thought provoking. The four existential givens (death, freedom, isolation, and meaninglessness) are rarely addressed in conventional therapies, though they may be at the very foundation of a client’s concerns. I think it can be important to be with clients wherever they are– even if it is a dark place. I see value in the core principle of this therapy, to assist clients in finding meaning in their lives, though we as people are finite, though we can only actualize ourselves within certain limits. In suffering and struggle, one has the opportunity to find meaning and self-definition in how she carries herself. I also see how many disorders can be conceptualized as an unwillingness to acknowledge our responsibility for being-in-the-world. An addiction in which one is obsessed with a set of behaviors or a chemical effectively serves to distance one from the circumstances of her environment, and also prevents her from acting in it.

I believe, as humans, we are always striving to achieve meaning in our lives. Nietzsche has proposed a will to power, but I think power is only one way we strive to imbue our lives with meaning or definition. Seligman has proposed that there are three approaches to happiness: the pleasant or pleasurable life, the good life, and the meaningful life. He emphasizes the latter concept, and particularly that the most fulfilling experiences will be those we have earned though action. We want to have earned our happiness. Pleasurable experiences alone (e.g., a delicious meal at a restaurant) can only provide so many fulfillments, as they do not aid us in our strivings for self- definition. I try to help clients generate more meaning in their lives and to help them to get back into the world by moving from being reactive to active. Often this includes an uncovering of personal responsibility and values, and helping clients to act in accordance with those values. Valuing makes certain behaviors possible, even if they make us anxious.

I am lucky in that I tend not to be too judgmental. Compassion is possible because I believe that all behaviors stem from needs and patterns of reinforcement. I do not feel pressure to make others believe what I believe, and I can be comfortable “agreeing to disagree.” Even if I have a strong belief, I can understand that clients must reflect on their own experiences for answers.

I hope that I am hopeful. In working with clients, I am less idealistic than when I started. However, I genuinely believe that all of my clients have unrealized potential for living better. I can see strengths in even my resistant clients, and I try to appreciate how maladaptive behaviors once served them. With respect to substance abuse, I also believe that relapse or a step in the wrong direction does not have to be a great setback; it can be an opportunity for learning and self-understanding. Erring does not take away all that has been learned in recovery or therapy. I try to encourage clients by recognizing small achievements on their way to larger goals, and I try to encourage recovery as a journey rather than a destination. As Dr. McWay said in his lecture this week, reflect on how difficult change can be, even for you as a high-functioning person…