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.
Two weeks later he was in my office. "Ken, I pissed right before I got here. Can we push the piss test back one day?" I told him no problem and started to make the change in the computer. Before I could finish he was back in my office sitting in a chair. "Don't" he said, "I used last night." His shoulders began to hunch, his face twitched waiting for my reply. I asked him "Did you spend more than you could afford? Did you start using again today?" He answered no to both and added "before it would have gone on for weeks." I asked him since he didn't lose anything, didn't hurt anyone, didn't put himself in danger, and didn't fail to meet any obligations, did it really matter that he used a little cocaine? We both sat for a moment. We were both a little stunned this was new territory for both of us. Then I asked him "do you still want to postpone the test?" He paused thoughtfully, "I'll take it today. I did the coke, and I can handle the consequences."
We continued like this. I told him he was welcome to report his cocaine use to me, but that I would not address it as an issue unless he told me it was. For his part he said it was his goal to stop using cocaine, but agreed that it wasn't helping to beat himself up over it. Each week he would stop in. Sometimes more than once. He would check in whether he used or not but he was using almost once a week. Sometimes he would take the drug screening and sometimes he would ask to push it back. I started to get nervous one week when he reported using three times. Was he falling into an addictive spiral? Had I given him permission to do so? But somethings else was happening. His permanent scowl was replaced by a relaxed smile. Where he used to rush in and out of the clinic as fast as possible, now he stopped to chat with nurses, old counselors, and even the management staff. He no longer walked hunched over but stood straight up and walked at an easy pace. He seemed younger.
Eventually the cocaine use stopped. Neither one of us could pinpoint the exact time, but one day he just didn't need it anymore. Even when his life became challenging again he didn't go back to it.
I would like to claim credit for his success but the truth is he had done a lot of hard work long before he met me. What he learned with me was that just because he hadn't achieve a goal, in this case abstinence, it didn't mean that he wasn't making progress towards it. In his case an imperfect abstinence was part of an amazing recovery. I didn't teach him that. We learned it together.
In my opinion the biggest problem with the use of drug screenings in chemical dependency treatment is that we use them for ourselves and not for the clients. We use them because we want to know if the clients are lying to us. We use them to have proof that we are successful. We use them because it's easy. But is it helpful? Should drug screenings carry the weight they do when deciding whether or not a client is making progress or is even appropriate for a particular setting? Of course not, I wouldn't be writing this if I thought so.
Here is a list of ideas to make screenings less punitive and more therapeutic.
1) Let the clients choose. There are those, myself included, who report the accountability provided by regular screenings was helpful in early recovery. A common factor between those of us who report this is we were fairly successful early on at achieving sustainable abstinence. To us the screenings were not accompanied by anxiety and shame, they were just another way to mark our success. So ask the client "do you think this will be helpful?" and accept it if the answer is no. In the end it's not important for us to know if the client is reporting honestly or not, only the client needs to know if they are using, and they already know.*
2) They don't need to be random. Let the clients know when the tests are coming, how often they are coming and what to expect from the results. Two concerns that immediately come to mind are that the clients may bring sombody else's urine or that they may time their use so that it won't be detected on the day of the screening.
I'm going to put the next sentence in bold letters because it is very important. Clients almost never bring in someone else's urine. It happens, but so rarely that it should be a nonissue! How much urine are you carrying on your person right now? Now go to a friend or family member who doesn't use drugs and ask them to pee in a cup for you. Don't tell them why you need it or better yet tell them you need it to fake a drug test. Please share the reaction you get on YouTube. Your clients are not lying machines. The vast majority of them if not all are with you to get better. They don't want to hide their use from you, they want to stop using. If you have a problem with clients lying about their use ask yourself, have you made your treatment program a safe place to be honest?
Clients trying to sneak a little use in during the safety window where it will avoid detection is much more common. In all honesty any client may be doing this at any time, but this is an important piece of information. Clients who can manage this are not using every day. That is huge. Don't worry about clients who are getting away with something. Clients who have a serious substance use disorder are very bad at managing this sort of thing so for what it's worth it's eventually going to show up on the screening. Better yet, if you are not judgmental, and you are supportive they will tell you they after they use. If possible Don't focus on the use at all. Focus on what they are doing right on the days they don't use and see if they can do more of it. If use doesn't show up on the screenings there will be other symptoms. If not, is a disease/disorder with no symptoms really a problem? Lastly, if a client requests a screening just so they can see a "clean" result, given them one, and when it comes back tell them "good job."
3) Measure progress in other ways. Abstinence is only one leg of recovery, and recovery is a many legged beast. When deciding if a client is making progress look at their attendance and engagement in groups. In my experience this has been the best indicator that a client will achieve some sort a of recovery and even abstinence, even if they continue to using at the time. Ask them how they are getting along with their families, ask them how work is going, ask them how they feel. Do they look better than when they walked in the door? For our clients progress in any of these areas will probably require progress in their abstinence goals, but not necessarily perfect sustained abstinence. At least not early on. Is it not the goal of recovery to have good relationships, stable employment, and to feel good about yourself? If they could have these things while using would we even care that they were on drugs?
One last point before I close. Observed urines, or the practice of watching a client provided the sample to make sure it's valid has almost no place in a therapeutic setting. It is dehumanizing, humiliating, and possibly traumatic to clients who have suffered sexual abuse. The actual and potential damage done by this practice far outweighs anything the client might gain.
*One exception to clients knowing when the use drugs can be benzodiazepines like Xanax and Valium. These can cause amnesia where the client forgets taking the drug.