Saturday, January 30, 2016

You Can't Test For It! Part II

You Can't Test For It: Recovery Cannot Be Detected in Urine (part 2 of 4)

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 probably should be.

He told me I was a "nice guy," that he could tell that by the way I said hello to him when we passed in the hall. This was the reason, he told me, that he agreed to come to the first session. He said he was a complicated case and while I was probably a fine counselor, he would prefer to return to someone he had worked with before. I disclosed that I knew something of his case and had in fact requested him for my caseload. I told him I'd only been a licensed counselor for a year but that made me more experienced than most of the others with openings on their caseloads. Also I was older than the others. I agreed to transfer him immediately if he still wanted and told him that he could still check in with me if he thought it would help. He seemed surprised, and his face momentarily twisted from his usual grimace, it softened. "Well that changes things" he replied "you got two weeks."

Remembering my own recovery I found the accountability of the random UDS helped me avoid some unnecessary experiments. I had endorsed that any alcohol use would put me at risk, but I wasn't convinced about weed. I didn't care much for weed, and only smoked it little more than one a year but knowing it would be detected helped me put it out of my mind. I didn't like it much anyway so why even bother. Each successful screening was a boost to my confidence, my feelings of self efficacy increased, I began to address other issues that were getting in my way. I imagine this is the case for many in early recovery, at least those who achieve abstinence early on. Even some  that struggle at first seem to find encouragement in the first "clean" urine. One client who struggled for months with abstinence is now almost giddy when required to do a random screen. Each clean urine is like a liquid gold star that month after month marks his progress. 

But what about clients who are not as successful with abstinence goals? We test all the clients with the assumption that some of them are not accurately reporting their use. When the sceenings indicate the clients is using, we the clinicians provide interventions that provide the client with a more realist view of their use which results in greater compliance with the treatment program and more successful outcomes. There are many problems with this theory.

1) Getting the clients to submit to a screening can quickly become a power struggle. Most of the more explosive behaviors from both clients and staff that I have witnessed came as a result of such power struggles.

2) The interventions are often punitive and shaming. Even when the treatment team goes out of their way to be nurturing and supportive the clients who has been reporting abstinence can be devistated when caught in a lie. Rather than improve the clients treatment this may make the client feel isolated.

3) The tests are sometimes wrong. False positives happen. This can put even a high functioning clients at risk.

4) Perhaps the most disturbing aspect of the screenings is the assumption of guilt. Clients that are doing well and clients who try to hide the fact that they are struggling report the same thing. Truth must be proved and proved repeatedly or it doesn't exist. The message we send to clients is that addicts are inherently unworthy of trust, and the clients more than anyone take this to heart. What do we get for this, we learn what we already know, that some clients continue to use while others do not.

I am not arguing that drug screenings have no place in the treatment of chemical dependency. I am challenging chemical dependency professionals to examine the way they use the screenings and to ask themselves how much they are truly being used for the benifit those who come to us for help. 

To be continued...

Thursday, January 28, 2016

You Can't Test For It! Part I

You Can't Test For It: Recovery Cannot Be Detected in Urine

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 probably should be.

He was a young man in his early 30s with shoulder length blond hair and an angry scowl chiseled permanently on his features. He had been at the clinic for several years, had struggled with his abstinence goals and had a reputation as a difficult client. He arrived on time for his first scheduled meeting with me as his new counselor. We exchanged greetings and each took a seat, after a short pause he looked me in the eye and said  "no offense, but I don't think this is gonna work." 

In every treatment program I have worked or trained at the Urine Drug Screen or UDS has played an important role. Chemical dependency professionals use the UDS for several reasons such as to show compliance to state and federal agencies, for safety reasons, and as evidence of compliance or non compliance to a given program. Many counselors swear by the UDS as a therapeutic tool which allows them to know for certain that a client is reporting their substance use accurately and to provide interventions for the client if illicit use is detected, especially if this use contradicts the clients report. It is also considered the most important indicator by everyone involved including clinicians, concerned 3rd parties, medical staff, and of course the clients themselves that what we are doing is working. A "clean" UDS is looked at as the most convincing evidence that the recovery process has begun and multiple "clean urines" are looked on as clear scientific proof that progress is being made. On the other hand "dirty" urines are considered proof that the clients is not making progress in recovery. If the client is consistently "dirty" it eventually overrides all other factors in deciding if the client is really invested in the program, if they " really want it enough." 

But even when a client is considered "clean" there is some suspicion, that they are providing someone else's urine, that they are just lucky and the substance is out of their system by the time they are tested, or perhaps that they are using a substance that is difficult to test for. This leads to the practice watching the clients as they pee and ever more expensive testing for the more elusive substances. It can become quite a chess game between clinical staff and the struggling client with both going to extremes to either catch, or get away with something respectively. For-profit labs will charge thousands for a single UDS and even send their own staff to observe the client and deliver the specimen. This costs the programs that contract them nothing as they bill the client's insurance company directly and the companies usually pay, sometimes once every week. Why shouldn't we be thrilled with this system? Sure it's expensive, but we catch the bad apples and send them away and for our wonderful "clean" clients we get that undeniable proof that all of our efforts really matter. My problem with this is that abstinence is only one goal of recovery, and in many cases it's not the most important goal. Addiction, or recovery from it, is not something that can be detected in urine. 

To be continued 

Tuesday, January 26, 2016

IT'S AN EPIDEMIC!!! (don't panic)

It's an Epidemic (don't panic)
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 probably should be.

Epidemic! Such an exciting word! Brings up images from history and horror movies of bodies in the street and society on the brink of collapse. Fingers have been pointing for years to find who to blame. Do we blame the doctors for filling medicine cabinets across the country with oxi and perc 30s? Or do we blame the drug companies who made billions supplying pill mills with unlimited product which then ended up on the streets? Do we blame the war in Afganistan for modernization of heroin production and distribution that has flooded the streets with so much heroin that some days it's cheaper than booze? We could always go back to blaming the addicts, but that thankfully is getting harder and harder to do. Now that heroin has found its way from poor inner city neighborhoods to wealthy suburbs and rural white comminuities it's harder for politicians to slap "other" status on the dealers and consumers of heroin and write it off as "somebody else's problem." Here on the east coast it's hard to find someone who hasn't lost a close friend or family member to heroin overdose, and some have lost more than one. In truth it doesn't matter who we blame. Blame has been as useful to a person fighting this epidemic as an anchor is to a person tryinging to swim the English Channel. It's something best left behind so we can focus on the task at hand.

Yes things are bad, it might even be that we haven't seen the worst of it, but this epidemic is treatable. We already have what we need to handle the situation. We just need to stop panicking. 

The war on drugs has lasted about 100 years. 100 years ago people panicked and decided to turn a small number of functioning addicts into criminals. Panic has driven drug policy since then to increasingly draconian measures on the mistaken belief that the problem is heroin itself or what ever drug du jour we are afraid of. Panic has driven us to wage was on cartels, arrest heads of state, and fill our jails so full that we now imprision more people than any other country in the world. Panic has driven us to treat an epidemic like an invading force rather than a disease and by doing so we've waged war against our fellow citizens. It's time to stop panicking. These panicked attempts to rid the world of heroin have brought us to where we are now. More people addicted to heroin, more people overdosing on heroin, more people dying from heroin than ever before.

We need to stop and take a breath. There are two medications with a proven track record in treating opiate addiction, Methadone and to a lesser extent Suboxone. We need to educate addiction professionals on the effectiveness of these treatments and stop acting as if they are as bad as heroin. We need to stop using prisons as the treatment option of choice for all addicts. We need to open our minds to any treatment modality that helps the addicted person return to the human experience rather than judge them for not recovering the way we want them to. We need to stop trying to punish the afflicted back to health.

For a history of the drug war and the damage its fear based policies have done to the world and to the treatment of addiction I recommend Chasing the Scream: The First and Last Days of the War on Drugs, by Johann Hari.

The author thanks you for taking the time to read Grey's Recovery. Feel free to give feedback on the ideas presented. Feedback on spelling, and grammar is not requested. Those who can't resist commenting on the author's spelling and grammar may be rewarded with a picture of the author's middle finger.

Monday, January 25, 2016

Monday, January 18, 2016

Rockstars of Recovery

Rockstars of Recovery 

Some clients are just easy. As a counselor they are a joy to work with. They show up on time, contribute to groups, and stay positive and engaged during individual sessions. These rockstars of recovery are very rewarding to work with as you can see them transform day after day and they almost always give too much credit to me. Though I indulge in some pride at the role I get to play in this type of client's recovery the truth is I do very little. Though they might say that I personally saved them and that they couldn't have done it with me the truth is they would be successful with almost anyone as their counselor and quite possibly, given enough time, with no help at all. 

Be grateful for these clients, they will keep you motivated after a tough week, they will write staff appreciation cards that look good in your file, they will send you emails and holiday cards long after you stop seeing them professionally, they will remind you your work is meaningful after a client you worked yourself crazy over ends up in the hospital after an overdose. What the rockstars of recovery won't do is make you a better counselor. I don't have much advice for working with this type of client, what follows should be taken as things to think about and not necessarily hard fast rules.

1) Make sure they don't overdo it:

The rockstars are only bad at one thing, self-care. They may fill their lives with appointments, charity work, and recovery meetings. They will talk at length about working at their children's schools and driving them to ballet lessons and look puzzled that they are always tired. Trying to get them to schedule something fun for themselves may be the most challenging thing you do for them. On the flip side, clients who struggle with continuing use while seeming to do everything right may become rockstars if you can convince them to take a night off and go to the movies.

2) Remind them that no recovery is perfect and all recovery takes time:

The rockstars will make amazing recovery in a short amount of time then beat themselves up for being late for your appointments. Frequent inventory of their progress and a reminder that they don't have to be good at everything may help. They may also want to fix everything at once, help them prioritize. Health eating is important, but giving up their drug of choice and retuning to work after long term unemployment are big changes to adjust to. If they seem to be struggling maybe work on coping skills now and save the diet for next year. I repeat this phase often "what you're doing now, plus time, will get you where you want to be."

3) Watch the boundaries:

Hopefully you love all your clients but the rockstars are easy to love. You will find that you are very at ease during sessions, watch that you don't over share. Also watch that sessions stay focused on the client, many rockstars ate sensitive and intuitive, they will know when you're having a bad day and want to help. The session is about their recovery not yours. I hope it goes without saying that though sessions may be intimate, and never more so than with the rockstars, the therapeutic relationship is at its foundation a professional one. The therapeutic relationship is sacred and any attempt to turn it into a romantic relationship is a violation of the client and your ethical responsibility as a counselor.

In conclusion it's good to remember that while working with a the rockstars is fun, it isn't challenging. The rockstars don't make you a better counselor because everything you try with them works. You don't have to be creative, you just have to show up and take the credit. Remember to be grateful for the client who struggles. Remember the gift of hope and courage they give you as they continue to show up even when they do not see the benifits right away. A client who is still coming to see you after a month of continuing relapse is demonstrating incredible faith in you so try and remember that when you count your blessings.

The author thanks you for taking the time to read Grey's Recovery. Feel free to give feedback on the ideas presented. Feedback on spelling, and grammar is not requested. Those who can't resist commenting on the author's spelling and grammar may be rewarded with a picture of the author's middle finger.

Wednesday, January 13, 2016

Primum non nocere part 1

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 probably should be.

When I started working as a drug and alcohol counseling intern, the concept of Non-Maleficence expressed by the phrase primum non nocere or "first do no harm" seemed childishly obvious.  Unfortunately harm is done in the recovery field and those who need us most are the ones most vulnerable. 


This topic is too big for a single post so I'm going to start with something simple that in my experience has reduced much of the harm I've inflicted and increased my love for the work. Most if not all of those I work with struggle with a sense of shame and unworthiness. One of the biggest mistakes I've made is to validate that feeling of unworthiness  when I thought I was helping. One way I avoid repeating this mistake is by changing the way I cope with the issue of honesty with clients. To the extent that I am able, I try and act on everything a client tells me as if it is 100% true. I may be a fool but I am not as naive as I sound. 


There is an overwhelming opinion in popular culture that the term addict and the term liar are nearly synonymous. Nowhere is this opinion more prevalent than among people who identify as addicts, and the reason for this is that they are indoctrinated to believe it. Addicts certainly lie, but so do teachers, doctors, religious leaders and captains of industry. While people lie for many different reasons, in my professional life people seem to lie most often for one of two reasons; they lie because they are afraid I will reject them if I know the truth, or they lie because they desperately want what they are saying to be true. 


It can be tempting to call a client out on a lie, to show them you're not stupid and they can't pull one over on you, but it is rarely necessary, usually traumatic for the client, and devastating to the therapeutic relationship. Also, the clinician who finds themself constantly looking for the lie is at risk of becoming cynical and jaded. The path to a trusting theraputic relationship is for the clinician to be trusting and non judgmental. Whenever possible,just let it go and it's almost always possible. Don't let yourself get pulled into the role of parent or truth police, it's a terrible job. When you must confront a client on a lie be understanding and remember people lie because they are afraid and desperate. Under the right circumstances we will all lie and it's up to us to create an environment where the truth is a safe option.

The author thanks you for taking the time to read Grey's Recovery. Feel free to give feedback on the ideas presented. Feedback on spelling, and grammar is not requested. Those who can't resist commenting on the author's spelling and grammar may be rewarded with a picture of the author's middle finger.