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.
I made it through my two week trial period without any trouble. I was confident all he needed was to refocus his energy from other peoples behavior to things he had control over. Once he did so I assumed he would progress quickly and for a time it seemed to be working. He was very open to the idea and it supported the 12 Step work he had done in the past. But then he started skipping sessions. When I did see him the angry scowl that was his only expression seemed to intensify. His shoulders hunched even more so that he walked like a man twice my age, though he was 12 years younger. Final reports of behavior issue began to reach me from other parts of the clinic, and when I addressed them in session he became angry and defensive. I wanted to blame him, to believe he wasn't tryinging hard enough, but the truth was he'd done all I asked. Something was missing. He had worked too hard for too long to be getting so little from his recovery.
Together we reviewed his time in treatment. His screenings showed reactive for cocaine every 3 to 6 months, but illicit opiate use hadn't shown up for years. His case notes told the story of a man who survived a life threatening accident that left him disabled, but who still managed to be a good husband and father and had recently returned to work. When I ask how he felt about his success he replied "I see what you mean, I can understand it when you say it, but I still feel like a failure." When I asked him why he thought that, he disclosed to me that he never really stopped using cocaine, and the it was eating him up.
This didn't make sense, he had said he was saving money, there were new shoes on his daughter's feet, his car was paid for, he was working full time, and most of his drug screenings didn't show cocaine. How was he managing this? He explained to me that he wasn't using every day. He tried to make each use his last. He told me he could often hold out for weeks, and never less than a few days. He explained the amount he used was never more than one or two lines, so the money was negligible, and often he payed nothing at all. But he felt tormented.
I proposed to him that we treat his cocaine use like any unhealthy behavior. He could report his use to me but I would give the use no more significance than cigarette smoking. If a random drug screening came up after a recent use he could report the use to me and I would document it in his case notes. He would have the choice of taking the screening or rescheduling for a later date.
The physical change in him was immeate and dramatic. His eyes opened all the way, his face relaxed and his shoulders unhunched for the first time since I'd know him. "Can't you get fired for this?" He asked. I told him not to worry, but I honestly didn't know.
When should a random UDS be a part of a client's treatment?
1) When it's needed for safety:
One might argue this is the reason for almost every drug test in a treatment setting but I would argue the test rarely increase a client's safety. One exception may be in Medication Assisted Treatment. Some drugs react dangerously with maintenance medications and arguably the risk is too high to count on the client's report. Even so mainainence clinics rarely test more than once per month so the UDS only provides a small window into the client's substance use.
It could be argued that illicit use in any setting is dangerous, and to some extent this is true, but does the test really make the client more safe? In my experience the tests drive clients away from treatment. Clients who know they won't pass a screening may not show up at all, and clients who do show up may be kicked out of a program. A client who is in treatment is much less likely to die from an overdose, but clients who are kicked out of a program die at the same rate as those who get no treatment at all. Better to create an environment where the client can safely report their use without fear of being discharged or forced into a level of care they aren't ready for.
2) Because it is legally mandated:
Sometimes due to state regulations the facility you work in will be required to give regular random screenings. As a counselor you have little to no control over these policies but you will invariably be the face of them and you may be able to lessen the shame these screening may cause. When the results of these screenings contradict what the client has told you don't use that information aggressively. Don't use the information as an honesty test to see if the patient will lie to you. Tell them in a nonjudgmental way the results of the screening and use it as an opportunity to ask the client what more you can do to support them. If the client has reported something inconsistent with the results there is no need to address the lie unless the client brings it up. This is an opportunity for the clinician to demonstrate that it is safe for the client to report their use honestly. Remember, the two most common reasons clients lie to you are 1) they are afraid if the tell you the truth you will judge and reject them. (so don't) and 2) because the want desperately for what they are saying to be the truth. (So help them make it so)
Sometimes a client may be mandated for random screenings as a condition of probation or parole. As a counselor it is important to remember that even though you are providing this service for law enforcement, you are not working for law enforcement, you are working for the client. While the client likely signed a release that give the P.O. access to the results of these screenings it is the counelor's ethical responsibility to advocate for what is best for the client no matter what the results. Continued reactivity may put a client at risk for being locked up, but so long as you have a comprehensive release for the P.O. there is no reason to send only the UDS results. Provide the results but also provide context. Does the client show up every day? Are they engaged in groups and individual sessions? Did the client recently suffer a loss that makes sustained abstinence difficult? Even if the client is less than perfect in all areas include your clinical opinion as to why incarnation is will not support the client's recovery because it almost never will.
I can't say it enough, if you must make random screenings a part of a client's treatment let them be informative, but never punitive. If it were possible to punish a person out of addiction the U.S. Prison system would be the most effective chemical dependency treatment in the world, but sadly it is not. So as clinicians there is no reason for us to borrow their tactics.
To be continued...
As always the author invites anyone to comment on the ideas presented here, but asks that you keep comments on spelling and grammar to yourself.