I'm not here to make friends

I'm not here to make friends 

 

When I worked for an inpatient facility I heard it at least once a week. Sometimes it was an individuals justification for isolating or sometimes for a harsh word, perhaps a cover for shyness, not wanting to show weakness. Often it was a declaration meant to show me the counselor how dedicated the individual was to recovery, a vow that the individual was willing to forgo most if not all of the softer parts of rehab and dive head first into the hard work that lay ahead. These folks were never without their journals and worksheets, they carried their Big Books clutched in their hands and read them at every break. "I'm not here to make friends!" They would say though they might have said another common mantra of the newly sober "I'm not like these other people." I would often lay awake at night worrying about these folks.

Two reasons I see this as a red flag 

1) RECOVERY CANNOT BE FOUND IN A WORKSHEET!

Let me say that again 

RECOVERY CANNOT BE FOUND IN A WORKSHEET! This goes for any worksheet. The free ones you find online, the expensive ones you purchase on your own and photocopy without permission, the ones that use a 4th grad vocabulary and the eloquent ones, recovery cannot be found in any of them. For that matter it can't be found in the Big Book either, it's not in a PowerPoint, a self help book, a video or in your favorite therapeutic card trick. In my opinion the vast majority of curriculum in rehab has very little value for the person in recover. These trappings are really more for we the professionals than those that come to us for help. They exist to make us look like we know 

 we are doing. They allow us to say "take two and call me in the morning" and fill the long hours with"programming" which the organization charges a sizable fee. Research indicates that educational lectures, videos and PowerPoints have almost no value for the person in recovery but many continue to lecture and play videos and continue to call it treatment. The videos give us time to catch up on our notes, the lectures are easy and one cannot invent the wheel on a daily basis so who can blame us? Because we put so much importance in these activities clients often mistake them for recovery. The "Not Here for Friends" folks most of all. So we take energy and focus which could be used more effectively and waste it on a hamster wheel.

2) MAKING FRIENDS MAY BE THE SINGLE MOST IMPORTANT THING ONE DOES IN RECOVERY!

The most damaging thing about addiction is how much it isolates. Humans are social creatures and we don't just want to interact with each other we need to. The Rat Park experiment if it can be applied to humans indicates that isolation and an inability to alleviate it by making new connections may be the key difference between someone who abuses substances when in a tough situation but stops when out of that situation and someone who gets trapped in a cycle of substance abuse becoming addicted . As chemical dependency counselors it is important to spot the clients who use our assignments as an excuse to isolate and encourage them to socialize. 

This does not necessarily mean clients should become friends with other clients though inpatient and IOP settings are a great place for clients to practice reconnecting. Your clients will likely come from very diverse backgrounds but all have a shared experience of struggling with substance use and of going through treatment. These things alone can be the basis for a profound connection. Many facilities are concerned with clients forming romantic relationships and discourage contact between clients outside of treatment. While I agree romantic relationships can distract from recovery the friendships that form can be a great support. The romantic relationships seem to form no matter what we do and I have to question if it's really any of our business if adults outside our facilities start to couple.

So we find ourselves with addiction that isolates, which may have been caused by isolation, we pull these people away and isolate them from friends family and work to treat them and to keep the lights on we professionals need to fill their day with programming so we can bill for our services. What's the solution? Obviously I don't know but here are some ideas.

Fewer lessons, more discussion. Keep the clients talking to each other not just to you. If you see that a client isn't joining the discussion prompt them and train you more outgoing group members to draw them out.

Focus on developing social skills. Role play uncomfortable social situations, talk about the clients anxiety over social situations and how to overcome them.

Make your homework social. Tell your clients to go to a meeting or some other sober gathering. Have them talk to 3 or more people. Have them journal about the feelings this inspires.

Make your programming fun. Provide the opportunity for your clients to take social risks and be silly in the safe supportive environment of your program. Play music, dance, tell jokes, or sing.

We may even wish to challenge the practice of isolating the clients from the outside world. Living in the world, rejoining the human experience is the goal of recovery.

I will not relapse over Donald Trump

I will not relapse over Donald Trump 

I haven't posted any original work in Grey's Recovery for months. There are several reasons for this and I'll briefly mention a few. One reason is that I now work for a mental health organization rather than a treatment center focused almost exclusively on chemical dependency. My title is Substance Abuse Specialist and I still run a group (two groups now) focusing on chemical dependency as well as providing individual counseling but much of my work includes clients who have significant mental illness and/or difficulty meeting basic needs and often I find that while these folks do have Substance Abuse issues they are not the number one priority. A second reason is I'm trying to get into grad school. Writing essays, chasing down people to write recommendations, and studying for the GRE take up much of my free time. Thirdly and the last reason I will present is my anxiety disorder is acting up. Coping skills I have learned in recovery are very effective in coping with anxiety so I have managed to stay functional in spite of the thunderstorm raging in my chest that periodically shocks me with bolts of agony. While my new job and the idea of going back to school at 47 are enough on their own to produce the occasional sleepless night by far the biggest trigger has been the unyielding fear that Donald Trump may soon be president of the United States. I'm almost 9 years away from my last drink but the relentless fear has brought back a longing for numbness for a short gentle oblivion that up until now was a distant fading memory. But I am not the man I was 9 years ago and I win or lose I will not relapse over Donald Trump.

Forget for a second that while the race has tightened Hillary Clinton is still favored to win. Forget also that a President Donald Trump will probably not bring about the apocalypse I fear, though he will most certainly damaged many of the causes I hold dear. I have completed numerous ABC exercises, identified my irrational beliefs and disputed them. I have also chanted the serenity prayer as a mantra that even as a nonbeliever I sometimes find comfort in. These things have helped but they have not been enough to end the silent torture my brain seems determined to inflict upon me. But win or lose I will not relapse over Donald Trump.

While it hasn't worked to address the anxiety itself which has gone off the rails and may not return any time soon that doesn't make me powerless here is what I can do.

 Accept that I am going to be anxious. This is probably the most difficult choice to make but expecting anything else is simply magical thinking. I am going to be anxious and with that anxiety will come a low frustration tolerance, poor sleep, and an ever present physical pain. But I've been here before, this is the devil I know. I have survived it drunk and sober and I will survive it now. I occasionally meditate on the anxiety, not to reduce it but to get to know it. I test its limits and sit with the pain. I step back and observe my mind running away with itself and remember that wherever my mind runs my body remains here. I occasionally take an ibuprofen to address the head and muscle aches but I resist the siren call of the dog's Xanax and of course the liquor store because I know the cost of the relief that will give. Numbing this will only delay the inevitable. I will have to face the anxiety either now or later, and if I send it away with chemicals it will return later with its friends. Worse still a chemical solution may compromise the tolerance I have built up over 9 years and validate the nagging thoughts that tell me I really can't stand this. But I can. Win or lose I will not relapse over Donald Trump.

My rewards for this path are considerable. For every 2 days I cope with the anxiety I get a day or two of feeling invincible, powerful, like nothing can keep me down. My nights have not been completely sleepless, I've even had a few nights where I've slept through the night. On the worst nights I still manage to get 3 to 6 hours of sound sleep. Not ideal but enough to function on. My anxiety is acting as a focus to practice mindfulness. In spite of my poor sleep I've had amazing clarity of mind and my compassion for people struggling with mental illness and addiction as well as my gratitude for those who support me my recovery is growing. My anxiety is killing me, it's helping me grow.

Only a few more days to go.

If anything from my experience helps you I hope you use it, even if you replace the name "Donald Trump" with a far more qualified candidate.

Enabling? Forget it!

The views in this blog are my own and not necessarily the views of my employer or any educational organization I may be affiliated with. But they probably should be.

"Enabler" is one of those words with people use when they want to sound like the know something about addiction, but both in and out of the field it is applied to so many different behaviors and situation that it is practically meaningless. In my experience the concept of "enabling" is usually introduced into the conversation about a difficult case just as the team is preparing itself to discharge the client or to use the threat of discharge to coerce the client into a higher level of care. In public it's most often attached to the parent or loved one of someone struggling with addiction but they never say exactly what they mean and I suspect they don't really know. I have NEVER seen anyone helped by this concept being introduced. I've never seen a case turned around by addressing "enabling." The reason may be that it is only introduced after the team has given up and is looking for a way to get rid of the living reminder of that failure.

So what is an enabler? Tell us Internet!

en·a·bler

noun

1. a person or thing that makes something possible.

   "the people who run these workshops are crime enablers"

   
   

   • a person who encourages or enables negative or self-destructive behavior in another.

     "he criticized her role as an enabler in her husband's pathological womanizing"

So in the business of recovery an enabler is something, a person, policy, or institution, that makes it possible for a person to use drugs. This sounds like a terrible thing. This begs many questions but the first that comes to mind is this. How are we making it possible for them to do drugs? Do we really have that power? In the case of the treatment centers who floated this concept as a reason why it might be in the client's best interest to be kicked out of the program, didn't the client use before they came to us? Then how did we suddenly take on this responsibility? We are not making it possible for the client to use drugs and I offer as evidence that most and possibly all of the clients discharge in in order to stop enabling in my experience continued using as much or more than they did before coming to us. It seems we aren't so powerful after all. 

But it is rare for treatment centers to be called enablers, the term is usually reserved for the parents and loved ones of people struggling with addiction and it is to them that it does the most harm. It is hard to watch someone you love struggle with addiction. Those who have to will at best find themselves awake with worry night after night and at worst will suffer profound trauma. The will watch the person they love go through ups and downs. They may experience numerous heart rending disappointments as promising starts turn to relapse again and again. They may have to bury their child. It is unbelievably cruel to tell them at any point along the way that it is their fault, that they could have stopped it from happening if only the hadn't been so kind.

Parents and loved ones have, like treatment centers, do not have the power to make it possible to use. They are not encouraging the behavior unless they are literally telling their children to use. But so I'm not at risk of being as vague as those who promote the concept I want to give some specific actions/behaviors that ate definitely NOT enabling. 

-Providing your loved one with food IS NOT enabling 

-Allowing your loved one to live in a safe place after a relapse IS NOT enabling 

-Giving your loved one a little money even when you suspect they are using IS NOT enabling 

-Telling your loved one "I love you no matter what. I love you if you relapse and I love you if you never use again" IS NOT enabling 

As for examples of things that definitely are enabling 

-I don't know. I'm not sure I've ever seen any

My recommendation for people with loved ones struggling with substance use is to forget they ever heard the word "enabler" and my advice to my peers in the field is to stop using it completely. Loved ones worry more about how healthy your behaviors are for you, but don't pretend you have the power to stop your child's addiction. If punishment were an effective treatment for addiction the U. S. Prison system would be the greatest treatment center in the world. It's not.

Rethinking Relapse

While standing in line at the pharmacy I was approached by a client I worked with at my former position at a small methadone clinic. There is always some discomfort when seeing a client in public because one must balance politeness with protecting the clients confidentiality, this is doubly important with methadone patients. That being said I love it when clients come up to me in public. He asked me about my new job, if I regretted leaving, might I ever work at a methadone clinic again.  He listened to my answers the told me the best news I'd heard in a long time. "I'm doing great" he said, "I've got take homes." I was barely able to pause long enough to ask permission before hugging him. 

He had struggled with heroin addiction for years, had gone to then dropped out of treatment many times over the last few decades.  He had been with my clinic long before I was hired and the year he worked with me had been filled with sincere promises to stop using followed by drug screens reactive for heroin month after month after month, until the last month. I wish I could take credit for it but it was a therapeutic relationship with a nurse on the team that got him to do what I'd been trying to do for a year. He overcame his shame about being on methadone, started to look at it as medicine instead of an extension of his addiction, and adjusted his dose to a level that let him quite heroin use completely.  All I did was keep the powers that be from kicking him out and I refused to threaten to kick him out. In spite of the reactive screening month after month he was making progress. He rarely missed a day, he was addressing health issues that had gone unmanaged for years, and he was learning and applying self care techniques. I knew if he kept on going as he was eventually the heroin would stop too. I was excited to see the nonreactive screen before I left for my new job, I was thrilled to hear that in the following month he continued to improve, but I was not surprised.

I don't like the word relapse. In my opinion true relapse is rare and almost nonexistent with a client who is engaged in treatment and when it does occur it is usually caused by the reaction of the treatment team rather than the continued use.  AA unofficialy recognizes that not every use is a relapse, the term "slip" is often used to differentiate a one time use from a full blown relapse. SMART Recovery distinguishes between a "lapse" which is a short return to substance use usually a single night to a few days and a "relapse" which can last from several weeks to several years. In the clinical setting we are often behind the support groups and treat every use as a relapse. Relapse is loosely defined as a return of all or some of the symptoms of addiction, one of which is problematic substance abuse and when I say it almost never happens I'm not saying people in treatment don't abuse substances, they do.  What I'm saying is, that when they do, it's not relapse. It's not even a "slip" or a "lapse." What I'm proposing is that the substance abuse in most of what we call relapse isn't the return of a symptom, it's a symptom that, like in the example above, just hasn't gone away yet.

The above client wasn't relapsing for most of the year I worked for him. He simply continued to use, regularly, possibly daily. There were many reasons for this, he had inadequate coping skills to deal with anxiety, he had easy access to large amounts of cash, and I near unlimited supply. But the main reason he kept using was he was so ashamed of using methadone to treat his addiction that he wouldn't let the doctors raise his dose to a therapeutic level. When he didn't supplement his methadone dose with street opiates he went into withdrawal and while he could make it a few days he couldn't achieve the sustained  abstinence from heroin that was his goal, so most days he didn't try. While this continued use may have slowed the clients progress and was a blow to his self esteem he did continue to recover. 

It might be argued that his continued use may not fit the strictest definition of relapse, but his continued use certainly put him at risk for it. I agree it is possible, maybe even likely that the client's use would have spiraled out of control and put all his progress at risk. Haven't all of us even those of us who have worked in the field a short time seen it happen over and over again? A client abuses a substance, maybe they tell us, maybe they just get caught. One use leads to another and after a time you see the clients asking for change on the street, read about them in the arrest section of the paper or worse the obituaries. There is one event that has always occurred between that first use and the sad ending, the clients is either kicked or driven out of a treatment program.

In short, if you are working with a client who walks into your office and reports they got drunk over the weekend I would argue they didn't relapse. They just haven't reached their goal of complete abstinence yet. As long as they continue to work towards that goal they almost can't relapse.

 If this happens

Do

Help them take an inventory of their progress, ask questions like "how are you reacting to this use now? How is that different from a year ago?"

Review coping and grounding skills 

Review needs and supports

Don't 

Discharge or threaten to discharge the client

Pressure or scare the client into a higher level of care 

Call it a relapse.

AA, it's personal

AA, it's personal 

I love the fellowship of Alcoholics Anonymous. Most of the friends I have made in my adult life I met in the fellowship. It was in AA that I learned to make friends again. AA didn't get me sober, but it helped me stay sober. Does AA help people? If you ask my wife and daughters they will tell you yes. Lacking a higher power it was often their voices that told me I needed a meeting. They were very aware of the transformation that occurred during the time I went to a meeting and the time I came home. AA helped me be a better version of myself.

The 12 Steps... I'm not so thrilled about. I'm a nonbeliever and white I can manage "higher power" as a metaphor I don't believe in the power of prayer. I love books, but I don't like to live my life according to the contents of a book. If I do it's by chance, not design. I have multiple copies of AA's Big Book, I haven't touched any of them for over a year. I went to AA for 7 and 1/2 years and will likely hit a few meetings in the future but I never did the 12 steps. Maybe step 1, but I've since reconsidered it. I learned from the steps, I learned to try and make amends and that doing so requires more than saying "I'm sorry." So what is my problem with AA?

This was/is my personal experience. It's an experience colored by my life situation, socioeconomic status, education, and white male privilege. Even as an atheist I found I was able to be an open atheist surrounded by believers yet I didn't feel like an "other" or "outcast." Because I have supportive parents, because I have a supportive spouse, because my children are heathy and I could get financial support when I needed it I was able to approach AA at my own pace and on my own terms. 

Luck, really good luck played a role. My first sponsor didn't stick but my second (hope he's still reading this) was a perfect match. When I said I wasn't comfortable with the Big Book or with all 12 steps he said "if you don't like 12 Steps, do 3. 1) don't drink, 2) don't think, 3) go to meetings. This 3 step approach worked very well for me.

So though I may sound critical of AA in some of my posts I don't really have a problem with the program itself. AA kept me alive for years, it was there for me when I needed it and it gave me what I needed.

What I have a problem with is this:

1) Court mandated AA. I think the founders would not have liked mandatory meetings either.

2) no training for sponsors. I had/have a great and ethical sponsor, but that is not always the case. Sponsors that are not ethical answer to no one.

3) AA in a clinical setting. AA is free. Anyone in any city in the United States can get free 12 step work. So why would 12 step work be part of  a $50,000 treatment stay? 

4) The rejection of medication assisted recovery. I don't think AA has an official position on methadone. However, the influence of the 12 step movement has been a barrier for people who need methadone and other medications in treatment. Again this is not AA's fault, it's the fault of treatment programs.

If asked about AA in a professional setting I treat it like church. Are you going? Do you think it helps? If yes, keep going. It should always be a choice.

The reason I rarely attend AA these days is also personal. Where I lived in Minnesota AA was pretty much all that was available. SMART Recovery meetings existed but they were few and far between.* after moving to Rhode Island and checking out several AA meetings that didn't quite feel right I went to my first SMART Recovery meeting. I've been going to SMART for a year now and I find it better meets my needs. If things go right I will soon be facilitating my own SMART meeting soon. I also don't have a problem with using SMART tool professionally. They are REBT tool that are very appropriate for a clinical setting and will work for people of any or no faith. Still I know I haven't attended my last AA meeting.

What are you selling?

The the practice of using half truths and outright scare tactics over science has left an indelible scar on the credibility of anyone in the recovery profession.  In the defense of myself and colleagues in the field our profession was started by faith healers, not scientists and these mystics have passed their trade from one generation to the next shouting down many attempts by the scientific and medical community to turn substance abuse treatment into anything like real medicine. While the mystics have been historically hostile to the legitimate researchers of the world they have been by comparison very welcoming to the snake oil salesman, and why not? They are the ones who sign our paychecks* and the close proximity with them has transformed many of us into a hybrid of the two. There are some promising changes happening right now which may lead us to better treatment for those who come to us for help but the first step is to stop pretending we know more than we do.

I started writing Grey's Recovery not to be a guru but with the hope of starting a conversation about things like this and in that spirit I'm going to start a list of things I learned both in treatment and while training to be a drug and alcohol counselor that turned out not to be true and I invite anyone who is still reading or happens to stumble upon this blog to add to the list. In the same spirit, if you see something that you think doesn't belong on the list please say so, and why.

IMPORTANT THINGS I LEARNED ABOUT RECOVERY THAT TURNED OUT TO BE UNTRUE 

1) Addiction has been proven to be a brain disease 

why not drop the big bomb first. Addiction has not been "proven" to be a brain or any other kind of disease. It has been "recognized" as a disease by several powerful medical organizations but this is a fairly recent development and it's my understanding this was done largely for billing purposes. It's hard enough to get an insurance company to pay to treat anything, even harder if what is being treated isn't an official disease. 

The truth is whether or not addiction is a disease is still very controversial. I personally feel the Learning Disorder model advocated by Maia Szalavitz in her book "The Unbroken Brain" does a better job of explaining the symptoms of addiction than any other to date.  The truth is the Brain Disease model explains very little. If drugs alter the brain in a specific way that causes addictive behaviors then why doesn't everyone who uses the drug become addicted? Why do compulsive gamblers and "sex addicts" have almost identical behaviors sometimes with no drugs at all? The Learning Disorder model explains this, the disease model doesn't. 

I feel I must tip my hat to Stanton Peele who has been arguing against the disease model since the70s. He has been a pariah in recovery circles for 40 years and I highly recommend people both in and out of the field read his work.

2) Addiction is ALWAYS progressive and ALWAYS fatal

This came right from an instructor in my first month of training said with braveheartian passion and made me feel an exquisite mix of fear and righteousness! I was very disappointed when I first read the watered down version in my text book replacing "always" with "sometimes," implying that addiction was often neither progressive or fatal. The truth is someone with any type of substance use disorder can remain stable indefinitely, and trying to force a change too soon is at least as likely to make the behavior worse than it is to bring about recovery. I've heard people who know better reply this myth as the truth in an attempt to get a resistant client to engage more in treatment which I see as nothing short of malpractice.

To my knowledge there is no reason for an otherwise healthy person to rush into treatment as long as there are no physical or psychological problems which combined with continued use might put the person's life at risk. If the person is stable, they will likely remain so at least for the near future and if left to their own devices may even recover on their own.  

3) The 12 Steps of recovery are the only "proven" treatment for addiction 

As a person who attended AA regularly for over 7 years it's hard for me to admit that this one is wrong. Many of us in recovery have a strong emotional attachment for the way we recovered and in this I am no different. But the truth is there is very little evidence either for or against 12 Step work. What evidence does exist is highly suspect and even the little that supports 12 Step involvement doesn't support it very well. I do feel being in AA was helpful to me, I found a good meeting where people respected the fact I am an atheist, and a good sponsor who did the same. I needed friends in early recovery and I found them in AA. But after moving to Rhode Island I just couldn't find an AA meeting that felt right so I found SMART recovery. 

SMART unlike 12 Step organizations is very open to scientific scrutiny. There is still the issue of anonymity and SMART attendees are not required to participate in studies or even give their names but in spite of this there is some very promising data that speaks to its effectiveness. I'm not saying that SMART is a cure all, I only mention it because most people in the recovery field have no idea that SMART Recovery exists and that it is at least as effective (and possibly more effective) as the 12 step alternative, but it wasn't mentioned once that I can remember in either my treatment or my training.

4) If you have a problem with ___________ you will never be able to use it normally again.

The watered down version of this is that some people are able to moderate use again but that the number is so small that it is statistically insignificant. Unlike the other things on this list it is possible that this is true, but I doubt it. The truth is we have little idea how many people are able to moderate use after showing addictive behaviors for a substance. What little data there is show that of people who had diagnosable alcohol dependency the percentage of people who may be able to someday drink with moderation is between less than 5, or slightly above 50 percent. I wouldn't stand behind either number, the truth is I just don't know. As hard as it is to count addicts it is even more difficult to count those who return to moderate drinking. In the field we only meet with those who try and fail, so it looks to us like a %100 failure rate, but the ones who achieve moderation don't come back to visit us. If they do they don't tell us they are drinking moderately. If they did we would treat them with suspicion. So we don't see them at all. Many of those who have achieved sustained abstinence may be able to return to moderation but don't try, because we tell them it's impossible. 

The few times a client has felt comfortable enough to share with me that they are thinking about returning to use I tell them I have no idea what their odds are. I do know that people who attempt lifelong abstinence often experience relapse so even that is no guarantee of success. So I tell them to be careful and to come back and visit sometime, even if they are successful.

Obviously the list could go on much further but I'm getting tired of writing. My advice is to avoid speaking in absolutes as they are usually false and to research any "fact" you find yourself repeating more than once a week.

Please feel free to call me a madman or a genius in the comments, I will consider either a compliment.

* when referring to snake oil salespeople I am not referring to my current employer or anyone I have worked for in recent years. I have been lucky.

 

Don't Let the Boogieman Be Your Boss

The regulating bodies for the mental health/chemical dependency field place a huge burden on the professionals in the field and that is never more apparent than when a client dies. You will lose clients. If you stay in the field for any length of time some will die. Some will die of health problems, some from violence, some will take their own lives, some will fall victim to very bad luck, and some will die of unintentional overdose. When this happens one or all of the regulation bodies will descend upon your organization and comb through your treatment notes. They may ask you uncomfortable questions, they may seem like the inquisition. You may feel unduly blamed, you may be unduly blamed and more than likely you will to some degree blame yourself. One of the worst things that can come from this is the professionals involved leave the experience thinking they can never let this happen again.

The worst policy and professional decisions are the ones motivated by fear. They usually take one of two forms, discharging a client who is deemed "too risky" to keep in your program because gods forbid they die on your watch, or putting so many unrealistic requirements on the client that they disengage or are driven away from treatment. While the death of a client under your care will require that you prove you did everything possible to keep the client alive, the death of a client shortly after discharge only requires you tried some type of intervention before the discharge. Threatening the client with discharge if they don't do A, B, and C counts as an intervention, no matter how unrealistic A, B, and C may be counts as an intervention and the regulating bodies will check that you documented the threat and leave confident you did everything you could.

So we can sleep at nigh we tell ourselves the clients brought this on themselves, that the clients failed we did not fail them. We tell ourselves we did it for the client's own good. When that fails us we resort to the Nuremberg defense, we say we didn't have a choice because if we had not discharged, if we don't continue to discharge similar clients, they will take away our licenses. The problems with this are legion so I'll just mention a few.

1) "They" the regulating bodies are not after our licenses. Not only have I never seen a counselors license revoked for continuing to treat a client who is struggling, I have never even heard of it happening. The counselors I've heard who lost their licenses (I don't know any personally) lost them for gross incompetence or unethical behavior like entering into a sexual relationship with a client. The regulating bodies need people doing our jobs so they can keep their jobs. The boogieman isn't real.

2) Even if you are answerable to a regulating body that will revoke a counselor's license for a sound clinical decision, our job is to help people to recover from substance use problems, it is not to protect our license. Usually doing the first doesn't exclude the second but to do this job right may sometimes requires a little courage.

Fear based decisions are almost never good clinical decisions if you let the boogieman be your boss you will hurt the people who need you the most.

Sent from my iPad

Scary Stories and Demon Drugs

Scary Stories and Demon Drugs

The views expressed here are my own and may not be shared by any organization I am affiliated with, but they probably should be.

Scary stories drive large portions of the world economy and it's not hard to see why. People don't sit through the evening news (is there still such a thing) let alone stay glued to a 24 hour news cycle to hear good news. They don't need mindless sitcoms to escape when they are happy.  While depression may drive a few people to the mall the real money is in fear. The same goes for politics. People don't rush to the polls because everything is alright, they vote because everything is going to Hell and the other guy or gal will only make it worse. Unfocused fear is as useless as joy to the entrepreneur so every good fear monger has to point the finger, a good target is usually found in criminals, minorities, communists, other countries, big pharma, or "incompetent" teachers, judges, and in this case doctors. But nothing makes a better target than a Demon Drug. Teachers and doctors have organizations to speak for them, big pharmaceuticals have billion dollar marketing campaigns, but a   Demon Drug, especially an illegal drug, can't speak out for itself and it makes a frightening antagonist for both the 24 hour news cycle and for a luxury rehab who will gladly help save you and your loved one from this monster, but not for free. 

The current Demon Drug is heroin but I'm old enough to remember when marijuana made the list. Heroin seemed like old news during the methamphetamine scare in the 1990s and early 2000s. The stories are always similar. The drug is incredibly addictive so much so a single use might ruin your life, it's deadly in the short term but if you manage to survive long term use will ruin both your physical and mental health, but most importantly it's coming to your neighborhood, it's coming for your children. Woven into the narrative is the idea that though things may be bad, we may even be on the brink of societal collapse, things would be much worse if the drug were legal. Law enforcement standing behind tables covered in the Demon Drug De Jour or hauling haggard looking drug dealers away in cuffs are cast as the only thing saving us from the brink. It's a thrilling story, but it's fiction, and we are suffering the consequences of 100 years of fiction driven policy.

 Any study of illegal drugs and drug users will always have a big margin of error, but the data that exists indicates between 1 and 2 people out of 10 who try heroin will have a problem with it. If you include legal opiates the number is much lower.  Oddly enough the number is about the same for meth and crack cocaine. Only 3% of all the people who have ever used meth or heroin have used it in the last 30 days. If the substance is as addictive as we are led to believe shouldn't the numbers be much higher? I've seen some make the argument "even if these numbers are true, we shouldn't make these drugs legal. If 10% of the people who try the drug become addicted to it, making it legal will cause more people to try it and that will make more addicts!" This is usually followed by some math assuming a 20% addiction rate followed by more scary numbers, but rarely do these story tellers realize that there is another Demon Drug that was legalized and there is no call from from the media, politicians, law enforcement, or judges from any part of the political spectrum to outlaw the drug again.

If any drug deserves to be demonized it's Alcohol. Alcohol related deaths dwarf those of any illegal drug. Long term alcohol use can be tied to early dementia and other mental and physical illness even when used in moderation. People using alcohol often become violent and foolhardy putting themselves and others at risk. There is no medical benefits from alcohol that can't be achieved through safer methods while heroin and methamphetamine both have legitimate therapeutic uses. But heroin, meth, cocaine, and if you're old enough marijuana are bad, alcohol is not.

But didn't heroin cause the current heroin epidemic? Doesn't that prove how much more dangerous it is? The answer is NO. The truth is we are not experiencing a heroin epidemic, we are experiencing an addiction epidemic. Yes heroin deaths are up but so are deaths from alcohol, the reason nobody is panicking is that alcohol deaths are always very high and the current uptick doesn't look so dramatic. Legalizing heroin would actually make it possible to reduce the overdose deaths. The truth is heroin addicts aren't dying from the drug they are dying from the drug war and the real horror story is the way we treat them. 

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The Meeting Makers

The views express may not represent those of my employer or any other organization I am affiliated with.

I started this little project I call Grey's Recovery to fill what I felt was a void in my professional development. I want to share my development as a professional in the chemical dependency field but also share my development as a person in long term recovery. The two things often don't overlap but they do parallel each other. When I make a decision, take an ethical stance, or more importantly change my ethical stance I can't help but feel the effects of that change from both sides. A major change which started in my professional life and has moved to my personal recovery is the role of AA and the 12 Steps. 

"Meeting makers make it" is one of the countless platitudes you will hear around the tables. We all know that people who attend regular AA meetings can achieve sustainable abstinence and by doing so long enough a richer more satisfying existence follows but that's often not the message of the person who pulls out this gem. The intended message is often that the opposite is not only true but but an absolute certainty. The message is that while meeting attendance and specifically 12 Step meeting attendance can't guarantee sobriety and a better life, not going to meetings will doom you to jail, institutions, or death.

Is this true? The short answer is no, but like all answers about recovery it's not that simple. The truth is that there are "meeting makers" that have very successful recoveries that grow into rich satisfying lives and there are some that get stuck in a perpetual circle of abstince and relapse that spirals into the very same jails, institutions, and graveyards reserved for the non makers. Those who don't attend meetings have a similar range of experience, some make it, some don't, and of course it isn't either/or for either group but a vast sea of grey between one extreme and the other. 

Do meetings help at all? Should you recommend meetings to a friend, loved one, or a client you are counseling? Should you make meetings a staple of your own recovery? If meetings don't guarantee success do they at least increase the odds of it? Funny how recovery turns us all into gamblers. The answer to this question is a less satisfying maybe. There is data to suggest that 12 Step attendees do better in recovery than those who do not attend, there is some that might suggest that there is no difference at all. Some experts have said 12 Step work with its dogma of helplessness actually does more harm than good.  I am not one of those people who sees all data as equal but if you are looking for clear scientific research that proves 12 Step attendance is helpful or harmful it really doesn't exist. 12 Step members are anonymous and that makes them hard to count. So what do you do? The answer is easier than you might think. You ask your friend, loved one, or client something like "did you try a 12 Step meeting? Was it helpful?" and the answer you receive will be the best indicator you will get. 

I will say 12 Step meetings helped me, but the 12 Steps did not. Through 12 Step meetings I broke through the isolation I felt in the years leading up to my problem with alcohol. I learned that sharing my struggles with a group was a healthier coping skill than drinking my anxiety away and brought people closer to me. I learned that I could have close meaningful friendships with people who believed in a higher power though I myself did not. With the help of the fellowship I recovered, grew, became a better person, and found my career. But I never did the 12 Steps. I maybe took the first, but even that I've taken back. My sponsor advised me that if I wasn't comfortable with 12 Steps I should try 3. Don't drink, don't think, go to meetings, and that's what I did for almost 8 years. That's what I still do, though I now attend SMART Recovery instead of AA. While I don't see myself regularly attending AA meetings again I don't think anyone who knows me would doubt I am far better off for having done so.

I broke with AA professionally about a year before I did so personally. When I started as a counselor I tried to take my personal experience in recovery and apply it to those I worked with. Meetings had helped me, meeting attendance had been the turning point that brought me from abstinence to recovery and like many new counselors I assumed some version of that experience would work for everyone. I suppose it worked about as well as anyone who practices 12 Step recovery counseling. I had several ethical problems with professional 12 step work.

1) I was using clinical techniques that were developed a long time ago and had changed very little. It felt like we were practicing surgery with techniques developed in the 1930s.

2) I was using a technique that in its instruction manual required belief in a higher power, something which I did not myself believe. 

3) I was paid for my services when there when the same service was available for free.

4) I became more and more concerned that the people who appeared to succeed after working with me could have succeeded with anyone or with no help at all.

5) Science, the lack of it.

I broke with the 12 Steps professionally after starting work at a medication assisted recovery center. While I could reconcile my discomfort in an abstinence only program I couldn't recommend AA and 12 Step work for clients on methadone and Suboxone. I couldn't recommend 12 Step meetings to my MAT clients because I didn't want them to have to lie about their type of recovery and I wasn't sure what reception they would get if they told the truth. There were "methadone safe" NA meetings in the area and some if my clients attended them. The center hosted a group called MARS which is a peer led support group for people in medication assisted recover that is not 12 step based. My office was across the hall from the MARS meeting and they were loud and proud of their recovery. I think MARS benefited my clients who attended but for the clients who went to NA it was a mixed bag. Some seemed to find healthy connections, others seemed to find more shame. The majority of my clients attended no meetings, and the majority of them did just fine.

As this post seems to be running away with itself I'm going to wrap it up. My point is I now treat meeting attendance much like I treat church. If a client tells me they are going to church and church is helping their recovery I assume that it is and tell them to continue. I make meeting information available to my clients but I make no judgment about the type of meeting they go to or how often they go. What the clients need is meaningful human connection, and while a meeting can be a place to make meaningful connections it isn't for everyone. I believe the client is the best judge of what will work.

Meeting makers make it and don't make it. What's more important is that one doesn't give up on positive change no matter how long it takes.

Selling Storm Clouds and Linings

The opinions here are my own and may not reflect those of my employer or any educational institution I may be affiliated with.

4 months after my last drink was the day I decide to kill myself. I was having panic attacks daily, they weren't just uncomfortable, they were painful. I ended up in the ER with chest pains only to find out my heart was very healthy. The people at the AA meetings just talked about how great sobriety was. Every day someone got a new job or saved there current one, I was barely hanging on to mine. Every night I dreamed about drinking and every day I was terrified of relapse.... and everything else. I figured my wife was already making plans to leave me and who could blame her? My oldest child was openly hostile to me, my youngest would hate me soon enough. I had always been anxious but this was different. Before I could make it through the day knowing that once I got home it would all be alright. But now without my chemical vacations the pressure carried over from day to day and I knew for certain any day now it would crush me. I remember when it hit me that I couldn't continue living like that, and if I couldn't live I would have to.... I started making plans.

I composed a note and saved it in a secure file. When I was ready I would copy and paste it to an email and set it to send shortly after the deed was done. I would leave for work in the morning but instead go to a secluded spot in the woods. There I would hang myself. My note would contain directions on how to find me as well as the numbers of some psychologists that could help them with the trauma. But I couldn't do it to my wife and kids. I tried to find studies on children whose parents killed themselves. I couldn't find much but what I did find wasn't good. In the best case scenario the children were scarred. Many grew up blaming themselves. I couldn't do it to them. So if I couldn't die I would have to.... I started making plans.

I realized that I was going to survive my recovery. I continued to struggle with depression and anxiety (I still do) but it was different. Once I realized anxiety wasn't going to kill me, that I could continue breathing through the worst of it, continue walking, working, living, it never had the same power over me again. Looking at my life now I can definitely say it was worth it, but back then I didn't know.

-Ken 

I didn't tell anyone for years how close I came to attempting suicide. I didn't tell my counselors for fear they would have me committed, I didn't tell my wife because she might blame herself, and I've never even told my children that they saved my life that day. They don't read this blog so it's possible they will still never know. The experience didn't make me stronger it traumatized me and I still get a cold shiver when I think about it. The strength came later with a lot of time and a lot of help but at that time I believed that my life would never get better.

What I hope this dark little bit of over sharing brings to the conversation is some perspective. When we are dealing with a client who can't see how lucky they are, who can't see how good their life is, it might be that it's not. The client's experience of early sobriety may be very different from how it appears to us. So what do we do?

Telling the client that things will get better will be of limited use but we have to tell them. If they trust us enough it may keep them going. More importantly we need to realize/remember that recovery isn't just wonderful, it's also very hard. Having to sit with the feelings that you once so easily numbed is bad enough. The idea that you have to do it forever is overwhelming. What finely saved me was a counselor who made me feel safe enough that I shared my anxiety in group. She in turn referred me to an anxiety group which in turn changed my life. There are worse things that can happen to a client than to relapse, and while the silver lining is real we can't ignore the clouds.

Breaking Up is Hard to Do

The opinions here are my own and may not reflect those of any organization I may be affiliated with.

The therapeutic relationship is often an intimate one. Clients may feel a profound connection to you their counselor and you may, I dare say will, feel connected to them. This is not a bad thing. As long as healthy and professional boundaries are maintained this connection can help drive the work you do together. Any intimate relationship brings with it a certain amount of vulnerability and this is never more obvious than when that relationship ends. 

I am currently in the process of telling my clients, many of whom I have worked with for almost a year, that I have taken another job and will no longer be their counselor. The responses range from mild disappoint bordering on indifference to feelings of crushing abandonment. As of yet no one has seemed happy about my leaving but in a way that only makes it worse. I love my clients. It's a love that exists within the ethical boundaries of my profession but it is love none the less. I wouldn't do this otherwise. Which brings me to two points that I try to teach my clients when I first start working with them and remind myself at times like these.

1) The therapeutic relationship, no matter how intimate, is not and should not be an exclusive relationship.

This is important. Clients may have theraputic relationships before, during, and after they work with you. Some with have styles that vary greatly from yours. Some may follow a treatment philosophy that is incompatible with yours. That's okay. The progress a client makes with you is not invalidated by the progress they make with another professional. One might argue that a client who moves from you to a successful relationship with another professional is the best indicator that you did your job right.

A client who has made great progress with you and worry that they may not be as successful with another professional. Acknowledge the relationship will likely be different but remind the client the progress goes with them. In the end it's the client's own strength that brings about change.

2) The therapeutic relationship is a temporary one.

If you are lucky you may get to watch a client grow for a long time, but the goal of our work was never to work with them forever. Some clients may become colleagues someday, even friends (but be wary of this) but at some point the theraputic relationship has to end. If not, it transforms into something else which may be a barrier to recovery.

       

Wrong Turns

The views expressed hear are mine and are not necessarily shared by my employer or any educational facility I may have some affiliation with. But they should be. Otherwise why would I be writing this?

People are starting to panic about opiate overdose and addiction in the United States. It was bound to happen as things are bad and maybe even getting worse. When people and policy makers panic they seek comfort in what they "know" which is particularly dangerous right now as what they"know" is almost entirely wrong and it will without a doubt cause harm to the people most hurt by this epidemic, and they are legion.

The first wrong turn is a focus on access. It seems we keep making this turn so often we are driving in circles. There is a belief that exposure to a drug is the cause of addiction but if this were true hospitals and doctors offices would be addict factories. Though the data shows that a person who is prescribed opiate pain medication is at a higher risk of developing opiate dependency it also shows us that the vast majority of addicts did not start this way. No one doubts that there has been access to prescription opiate over the past 20 or 30 years, and that may explain why we have a spike in opiate addicts, but why is there an increase in alcohol overdose deaths as well? Is there suddenly more access to alcohol than ever before? People aren't talking about the increase in alcohol overdose because it's not as dramatic of an increase. Why? Because there have always been a large number of alcohol overdose deaths in the country. Yet there is still enough of an increase to be statistically significant even though to my knowledge big alcohol is pushing its products no more than usual and doctors aren't prescribing it. The fact is the role of access in the development of a chemical dependency is far from clear but that doesn't stop self proclaimed experts from claiming it is.

One brand of snake oil being marketed as part of the solution comes in the form of Abuse Deterrent Formulas or ADFs used in prescription opiate. ADFs come in several forms, none of which will stop addiction and may cause additional harm to those addicted to them.

1) Formulas that prevents crushing of the pill for snorting or dissolving it in water for injecting.

Why it won't stop adbuse/addiction 

Humans are very clever. I've heard of one formula that caused the tablet to turn into a gel when crushed, people wishing to snort the drug put the pills in the freezer for an hour and found the could crush them quite easily. But even if the formula worked there is nothing to keep people from simply taking more of them.

Why it might hurt?

People with substance use disorders make mix additional chemicals to the drug to get them to dissolve which may increase the risk of use.

2) Formulas with an added irritant that will cause discomfort if snorted or injected.

Why it won't stop adbuse/addiction

People who are desperate enough will inject or snort them anyway and again there is nothing to stop the person from simply swallowing more pills, which by the way is the most common form of abuse.

Why it might hurt?

These irritants may damage the mucus membrane of the nose and or the veins of the people abusing them. These formulas are not a deterrent for abuse, they are a punishment for those already addicted.

So if ADFs aren't the answer we should just stop using these medications all together right? This is the next wrong turn. Why do I know it won't work? Because it's already failed.

In the 90s and the early part of this century it was relatively easy to get a prescription for opiates. Go to your doctor and point to the 10 on the pain scale and you could walk out with a sizable bottle of pills to get you through the day. If your doctor started asking questions a number of "pill mills" opened up around the country who's job it was to write the prescriptions and supply both addicts and dealers to almost limitless amounts of opiates. The situation was far from ideal but there were some advantages. People knew what they were taking and the pills were so cheap it wasn't cost effective to counterfeit them. Having this largely unregulated stream of opiates supplied to the general public seemed like a bad idea. Clinics were shut down, doctors were arrested, pills became expensive and hard to get. 

But rather than decreasing opiate addiction and overdose deaths, people switch from largely unregulated prescription opiates to entirely unregulated heroin. Opiate overdose deaths are now the highest they have ever been, but we couldn't have known that would happen. It only happened before 100 years ago when opiates were first outlawed.

The CDC is already trying to double down on this wrong turn by releasing guidelines in an attempt to further limit the supply of relatively safe prescription opiates, this will likely result in more heroin use whic will hit the signal for the final and most costly wrong turn, a big law enforcement push.

We can't afford to keep driving in circles. We've been going in circles so long that we've dug ourselves a hole. How much longer can we go before it's too deep to clime out?

 

The 12 Steps of Chemical Dependency Counselors

The opinions here are all me, not the guy who pays me.

I don't think that it's news to anyone who as been through or worked in a treatment program for chemical dependency that the staff, and sometimes the very programs themselves, behave a lot like addicts. Yes many of us are in recovery but that's not an excuse because people in recovery are wonderful to be around. We behave like addicts for the same reason addicts behave like addicts, we take responsibility for things beyond our control and when things start to fall apart we end up using the same counter adaptive coping skills to keep it together. If it goes too far those of us in recovery put that recovery at risk and if the process isn't stopped these behaviors become writen into policy until the entire organization begins to stagger along like an alcoholic in full relapse.

We lie. The most common type of lie is by omission, for example we rarely admit that more than half our clients will use again within 3 years, most of those within the first couple months after treatment. Many of the lies of omission involve clients' rights. These rights can seem inconvenient when we think we know what's best but the client disagrees so we may neglect to tell them that they have the right to refuse. Doing this however is also violation of clients rights.

We blame others for our failures. Usually we blame the clients, but often each other. When clients act out we say they "aren't ready" or "don't want to put in the work." Or we blame a colleague for allowing the behavior in their group. 

We get stuck into thinking if one thing is wrong everything is wrong. We fail to see progress in our clients and colleagues and focus only on their mistakes and we take them personally assuming ill intent.

Honest communication and self care are the best treatment for this, but for the fun of it I came up with 12 Steps for counselors. I'm probably not the first one to think of this and these 12 steps should be considered a rough draft or work in progress if they are considered at all. Please feel free to write your own 12 steps or suggest revisions to mine in the comments.

1) We admited that we do not have the power or the right to change someone, we can only try to create an environment where it's safe to change.

2) We came to understand  that forces beyond ourselves and our programs will ultimately decided if a client heals or not.

3) We made a decision to do our best without knowing the outcome.

4) We looked at our strengths and weaknesses as clinicians.

5) We openly discussed these strengths and weaknesses with supervisors and peers and did not try and hide them from our clients.

6) We were open to feedback from superiors, peers, and clients, even if we did not agree.

7) We sought  education and training where appropriate and had faith that our clients had a sincere desire to change.

8) We acknowledged situations that could have been handled better or when we were flat out wrong.

9) We took responsibility for our part in these situations and whenever possible made amends to the clients and/or colleagues affected by it.

10) We continued to be open to new ideas and for opportunities to improve.

11) We practiced self care for ourselves, both mentally and physically.

12) Then after achieving a healthy life/work balance came to understand what a privilege it is to work in this field and what a gift it is to be of service to people who are struggling.

Abstinence = Harm reduction

The views expressed here are my own and may or may not be the same as any organization I am affiliated with. 

I received an email from my Twitter account (https://twitter.com/greys_recovery) recently telling me I had been added to a list of "harm reductionists." I barely know how Twitter works, I don't know what it means to be on a list but I don't dispute that what I write is consistent with the Harm Reduction model. What surprises me is that people still make a distinction between "abstinence" recovery and "harm reduction" recovery. 

An abstinence goal falls under the umbrella of harm reduction. I've heard abstinence called "the ultimate harm reduction" though I'm iffy on th "ultimate" part. As I've said repeatedly before I think abstinence is often mistaken for recovery, chemical dependency treatment professionals often treat people like abstinence is recovery but few if anyone, 12 step to whatever I am argue that abstinence alone is all that it takes to begin and maintain a recovery from chemical dependency. What people often mean when they contrast abstinence with harm reduction is 12 Step vs well, anything else, but the language in the AA Big Book and what I've heard said around the tables for 7+ years is in inconsistent with a harm reduction model, if you remove the spiritual aspects of 12 step work the difference is even harder to spot. 

1) The 12 step community have their own word for abstinence only people in recovery

If you sat in on a few given 12 step meetings you will hear someone use the term "dry drunk." This is a person who has quite drinking (or stopped using their drug of choice) but has made no other changes to support recovery. The dry drunk can be anywhere from a day to many years sober. Basically they are a person who gave up their primary coping skill and replaced it with nothing. The dry drunk is painted as a  tortured and miserable soul, always losing his temper and blaming others for his woes. Basically all the problems of an alcoholic with none of the fun. But does the dry drunk really have all the problems of an alcoholic? Imagine there are fewer trips to the ER, fewer trips to jail. The dry drunk is probably not the most popular person  at work but there probably isn't a lot of sick days. There is probably very little cirrhosis of the liver among dry drunks if they can manage to keep from relapsing, but that's the rub, the dry drunk's quality of life is such that they seem at high risk for relapse or self harm. 

2) Abstinence is usually a long term goal 

There are a small percentage of people who have their last drink or use one or more days before they enter treatment for chemical dependency. Whether you make a distinction between a "lapse" a "slip" and a "relapse" there is, for most people in recovery, some substance use between the time they decide to change and the time they meet their goal of total abstinence. The number of people who enter treatment and maintain complete abstinence for 10 years is less than 1 in 10. Of the remaining 9 the extent of that use and the damage it does to their health and their lives  varies greatly. Most get some benifits from trying to achieve a goal of complete abstinence even if they never maintain the goal permanently.

3) Abstinence or *Abstinence 

Even in AA abstinence has never meant staying off everything. The Big Book is pretty clear that you should still take the medicine prescribes to you. Addictive substances were and are routinely consumed at AA meetings all over the world. One might argue caffeine addiction is fairly benign, but up until recently most meetings were filled with tobacco smoke. Even today tobacco is smoked outside openly before and after most meetings with little or no concern that those who partake are not really in recovery. Would they give the same deference if they were smoking marijuana? What of a methamphetamine addict who occasionally has a beer after work? There is still much debate on how risky it is for people addicted to one substance to recreationally use another but the evidence seems to show it is possible for example to be in recovery from alcohol and still smoke weed.

Both camps seem to agree that abstinence alone isn't enough to heal someone from addiction just as exposure to a substance alone doesn't make you an addict.  

 

Something Deadlier Than Heroin; a few easy steps to keep your addicted child alive

The views expressed here are my own and are not necessarily shared by any employer or educational institution I may be affiliated with...but they should be. 

It is an inconvenient truth that most of the deaths attributed to heroin could have been prevented, would have been prevented, if not for the drug war, or as I called it in an earlier post, the drug holocaust. Heroin dependency doesn't have to be a death sentence, there are effective medications that can reverse an overdose, and heroin dependency is arguably the most treatable of the substance use disorders. So why all the death? Why the black balloons the other day? While it is true, both overdose and dependency are treatable, all substance use disorders carry with them a stigma that keep people from treatment, and this is doubly true for heroin dependency. But this doesn't have to be the case, we can stop these deaths, we can change the way people look at substance use disorders, but this time it requires us to change, not the the heroin dependent.

While cleaning your daughter's room you come across a hypodermic needle and some other strange objects that a quick google searche helps you identify as her "kit." Suddenly it all makes sense, your daughter is using heroin. You can confront her, get her to promise never to use again, watch her like a hawk, ship her off to rehab, the list goes on. People are doing this all over the United States, families and communities are being ripped apart and the overdose deaths keep rising. What I'm going to tell you isn't a guarantee, but it may be the best chance you have of keeping her alive until she can find a treatment that works. But I warn you, you're not going to like it.

1) Encouraged her to use in front of you.  

This is the hardest, but most important step. Everything else hinges on this step. This means you take a hard look at the ugly reality of addiction and make a choice to keep your daughter alive. This requires you to choke back the words "don't you ever bring that shit into my house" because those are the deadliest words you can say. Instead say "I will always love you, you will always be my child, this will always be your home, heroin can never change that." This may not require you actually watch her do the injection, but encourage her to tell you when she is going to use. Ask her to return to the living room when she's done. Check on her often, learn the symptoms of overdose and watch for them. If you have other children in the house this may require some safety precautions.

                      a) a place to store her kit where the other children won't find it.

                      b) she will need clean needles, needles should not be use more than once even if she     isn't sharing them. In Rhode Island needles are available without prescription and affordable, if this is not the case you may need to contact a needle exchange, or order them online.

                      c) she will need a safe place to put used needles. An empty plastic detergent bottle makes an adequate sharps container to transport them for disposal.

You may ask if this is legal. The truth is I'm not sure. The greatest risk of arrests and prosecution occurs when purchasing and transporting drugs, assuming the amounts your daughter is purchasing are small it is probably not very likely that you are at risk for legal action, but it is probably possible. You will have to weigh the risks and see if they can be avoided vs. the danger to your child. 

If your child is acting out violently, or making threats of violence, step one may not be possible. Step one is about the safety of your child or loved one, but your safety is just as important.

2) Buy Narcan, and learn how to use it.

If your child overdoses you can keep them alive and reduce the risk of brain damage with rescue breathing and Narcon. Narcon is available in and injectable form or one that is administered nasally. The FDA has recently approved a new single use nasal spray for Narcan. Several states have made it legal to purchase Narcan over the counter, if this is not the case where you live a needle exchange may be able to provide you with some. Even if you don't have Narcan, rescue breathing may be enough to keep your child alive until help arrives, but if your child overdoses on the street, all the Narcan in the world won't help her, that's why step one is so important. You should keep Narcan around even if your child hasn't used in a long time. She will be at a higher risk for overdose if she relapses.

3) Consider ALL treatment options ...

...except rapid medical detox. It may seem like a great idea, but it's not. Even if your daughter successfully completes the detox and gets some sustained abstinence under her belt (few get even that) she will be at a higher risk for overdose. Inpatient treatment has the same problem. If your daughter makes it through the withdrawal symptoms she may very well be able to stay off opiates, while she's in treatment. Once she is out her tolerance will be lower and risk of overdose higher. This is not to say people aren't successful at this type of program, but if you decide to go this way steps 1 and 2 become even more important. Some data shows that people who go to abstinence based inpatient treatment are more likely to die of an overdose than people who get no treatment at all. This suggests the treatment can be more deadly than the disease. It's also important to remember that between 60 and 75 percent will relapse in the first three years, most of those within the first couple of months. To put it bluntly she is probably going to use again so instead of trying to prevent relapse, prepare for it. See steps 1 and 2.

Medication Assisted Treatment also called MAT may give your daughter the best chance of a successful recovery as well as provide more safety. There are disadvantages to MAT, the treatment is most successful if used as a long term treatment strategie, and the difficulty of discontinuing the medication. There is also the dependence on a clinic or provider to supply daily doses of the medication, disruption of which will be debilitating to the patient. But there are advantages as well. MAT therapy is cheap when compared to inpatient rehab and certainly cheaper than a daily heroin habit. It's very effective. Of the patients on a MAT program for 1 years 70% are illicit drugs free. You can continue working at your job on a MAT program, raise your children, go to school, and if you do relapse, the medication causes a cross tolerance that reduces the risk of overdose. For many heroin dependent people long term MAT is simply the best option. What's important to remember is to not push your daughter to stop taking her methadone or Suboxone before she is ready. The rules of thumb for methadone is to recommend 2 years of stability on the medication before attempting to taper off. Most will try to taper off sooner, many will stay on much longer, a few will take the drug for the rest of their lives. It's important to remember that it doesn't matter which of these categories your daughter falls into. One is not more sober than the other.

There is no right way to recover, there is no perfect treatment, whether you daughter goes into a Faith based abstinence programs, or a methadone clinic, odds are that her last use of heroin won't be the day before she starts treatment. Relapse is a part of recovery and even in a MAT program it can take months to reach a blocking dose and illicit use to end. But heroin is treatable, your daughter can survive dependency to heroin. Shame however will keep her from asking you for help. Shame will get her to quit her MAT program before she is ready. Shame will drive her away from you and into the streets when she relapses. She may survive heroin, but shame will kill her. It is time to stop waging war on heroin and people who use it, instead let's fight the stigma. Shame is deadlier than heroin.

Some bad advice for new counselors

She finished telling her story and pause to take another tissues to dry her eyes. The tears were still coming, but the sobs had ceased. Her face had the serene look one gets after a good cry and I could see she had gotten what she needed. "It's nice" she said "to have someone neutral to talk to."

"Thank you " I replied, "but I want to make one thing clear. I am not neutral. I am your counselor, I work for you, I advocate for you, it is your wellbeing I'm concerned about, so while I may be able to offer some perspective on these situations because I'm not in the middle of them, don't mistake that for being neutral. I'm on your side."

-the best counselor in the history of addiction (2016)

You can't let it get to you...

You got to have a thick skin...

You can't take it personally...

You can't get attached...

You can't bring it home with you...

You can't be too sensitive...

you can't let your feelings get in the way...

...if you're going to survive at this job.

It would surprise me to hear a new counselor say they never got this kind of advice. It would surprise me if they made it to the end of their first day of internship without hearing some combination of the above. Though the words may very slightly the message is always the same, you need to harden your heart, hide your true feelings, and is usually followed up with something about consistency and enforcing the rules. This is often delivered with a Dirty Harry voice and a far off stare. I often wonder if they think they are the first person to ever tell me something like this or how they would mistake this cliché for hard won wisdom. This are the people who will ask "what kind of message are we sending?" but rarely question if a policy or procedure is good for the client. I'm going to offer my rebuttal to the first and the last of this bad advice, if you ever want to see a condescending shake of the head, share this with Dirty Harry.

You can't let it get to you if you're going to survive in this job

To this I say, it is going to get to you, so make peace with it. 

"It" in this case can be a number of things. The mother of addiction is trauma and if the clients you work with didn't experience trauma before they started using, it happened soon after. I dare say most will have some combination of both, and some will come to you fresh from the abuse, and return to it at the end of the day. This should get to you. This is tragic. When a story affects you it's not because you are doing something wrong you are doing something right. By accepting this tragic and beautiful part of yourself you can seek support from a trusted colleague or supervisor. If on the other hand you pretend it doesn't affect you there is a risk you may get truly overwhelmed, this can lead you to cynicism and deny your clients the therapeutic connection they need to heal.

"It" may also be verbal abuse, unfounded or exaggerated  complaints to your supervisor, or some other behavior by your clients. Yes our clients come to us when their lives are out of control and yes sometimes they will lash out at you in an attempt to regain some control but it is okay that this hurts your feelings. You are rarely what the client is really angry at and sometimes these incidents can transform into powerful therapeutic moments. But if you don't leave yourself open to it, you may miss the opportunity. This job requires courage to do it right, and in this case it's the courage to be vulnerable.

"It" may be threats of violence. This is the line. Once it happens the therapeutic relationship is over and the the only ethical thing to do is sever professional contact. Don't try to bring it back under control, tell your supervisor and never meet with the client again. Ideally never speak to them again. This doesn't mean you must abandon them. It's fine to refer them to other services, after all they are still suffering and they still need help. It is also find to report the threats to the police. It may be they will have to find what help they can while locked up. It is important that your clients feel safe, but your safety is equally important. It is also okay to feel hurt, or angry, you may be sad about having to let them go, in this case you may want to pass their aftercare to someone else.

"It" may be death. I can almost say "it" will be death. Sometimes it won't be related to their addiction, but usually it is. It's okay to morn them, in fact, we owe it to them. Whether they were rock stars of recovery or the worst contrarian we were a part of each other's lives. Morn, heal, and get back to work. People need you.

You can't let your feelings get in the way if you're going to survive in this job

To this I reply, your feelings are the way. Dirty Harry thinks the clients will use your feelings to manipulate you he's right, you will be manipulated. But Dirty Harry will be manipulated too, the difference is he will be completely oblivious to this manipulation. 

I have been a sensitive person my entire life, and for the majority of that life I was told my feelings were a weakness, something to be ashamed of. Men aren't taught how to cope with feelings and I drank myself into addiction trying to deny mine. Now I realize my feelings are one of my greatest strengths both professionally and personally, they are what connect me to other people, they provide me with a rich and rewarding existence. The price of that is that sometimes I don't feel good. It's worth it. That's how I survive this job.

Ken