Wednesday, March 23, 2016

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.

Wednesday, March 16, 2016

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 ( 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.  

Saturday, March 12, 2016

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.

Friday, March 11, 2016

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.


Wednesday, March 9, 2016

Climbing quicksand mountain

Some days you will be showered with gratitude for showing up to work and sitting in your chair, sometimes you will bend over backwards, work yourself to exhaustion, and find the beneficiary of your effort has complained to your supervisor. This is the business, this is our sacred work. All you can do is your best, and you can't do that all the time.

Be grateful for the good days but remember it's the hard days that earn you your poverty wage. Don't give up. What we do is meaningful, even on the days we don't do it particularly well.


P.s. No one complained about me today. It's just an example of what happens sometimes.

Monday, March 7, 2016

Why I Would Buy My Daughters Heroin

Why I Would Buy My Daughters Heroin

The views expressed here are my own and are not necessarily shared by any employer or educational institution I may be affiliated with...but who could blame them. This one goes too far.

I have two daughters ten years apart who are similar and different as night and day. I consider myself a pacifist, but I know I would use violence to save them if they were in danger. I might use violence to save them even if there were another non violent way. They are my daughters, and I would not bet that my ideals could withstand a threat to them. But what to do if they were ever a threat to themselves?

I work in a medication assisted recovery center, that's a nice way to say methadone clinic. I work as a chemical dependency counselor, I'm good at it, and though I don't count myself as a believer, this feels like a calling. In the relatively short time I've worked in this field I've worked with several individuals who were unfortunate enough to be born to parents who kicked them out on the street at a young age to fend for themselves. Usually they did this because the child way gay, lesbian, or transgender. I was and still am disgusted by this sort of thing. To abandon a child to what mercy they can find in the world is not only a violation of parenthood, but of our very humanity. While I understand the forces that drive a person to such a barbaric act I have no sympathy for it. I don't care what your parents did to you, what they taught you in school, or what your holy book tells you, you simply need to be better than that. To fall short is unacceptable. But until recently I had some sympathy for the parents of drug addicts who did the same thing. What do you do with a child who continues to use drugs, even after you have sent them to treatment? What do you do when they lie and steal from you to support their habit? What choice do you have if they refuse to go back to treatment after a relapse? Aren't I hurting them more in the long run if continue to enable their behavior?

I don't know the answer to the above questions, but I know one thing for certain. No person I have ever worked with has ever been better off for having been kicked out of their home. Drugs may be bad for your child, but the street is worse. Any child is vulnerable on the street, a child addicted to drugs is even more so. There is no shortage of people waiting to take advantage of such children. 

The reason parents abandon their children for drug use is they have been told that continuing to support their child will keep them stuck in addiction or make their addiction worse. The only alternative is to cut ties with the child, cut off all support, and hope the child gets desperate enough to change.

In reality what happens is that parents trade one option that might hurt the child for one that will almost definitely hurt them. A child has precious little to barter for the things they need. If the child is already tortured by shame for being unable stop using drugs, imagine how much worse it is for I child who has had to sell their body, not just for drugs, but for food and shelter, and sometimes they will offer themselves and get nothing in return. Drugs can hurt your child but that kind of trauma can leave scars that from which they may never fully recover. The other option is to prey on others, any child who has to survive on the streets will probably have to do both. I won't do that to my daughters. 

I would sooner buy my daughters heroin and help them inject it before I would kick them out of my home. It wouldn't be my first choice, but if it came down to it that's what I would do. Being a drug addict is not a fate worse than death. I may not be able to protect my children from everything. But I will protect them from everything I can.

Wednesday, March 2, 2016

A little bit about abstinence and recovery

A little something about abstinence and GREY'S recovery 

The views expressed here are my own and are not necessarily shared by any employer or educational institution I may be affiliated with...but try not to hold that against them.

I had skipped lunch and instead run three miles on a treadmill. 4:30 PM on the way to my night class at the community college I decided to stop for a burger and a beer. I never got the burger. Sometime after 10:00PM, the details are a little fuzzy, local law enforcement decided it was no longer safe to let me "walk" on public the public sidewalks. I was searched for weapons, poured into a pair of handcuffs and placed I the back of the patrol car. After holding back tears and making sure my voice wouldn't crack I managed to ask "am I going to jail?" They told me no, that they would just take me to "detox" where I could sleep it off for the night. But had this scenario played out a few minutes later their answer, and my life afterwards may have changed dramatically. While my memories of that night are foggy at best I do know one thing. I was on my way to my car. 

February 3rd, 2008, sometime close to midnight my Blood Alcohol Level was around .27 or three times the legal limit to operate a motor vehicle and in my case, a pair of shoes. I count February 4th, 2008 as my "sobriety date" and if I keep going I will soon be able to boast 3000 consecutive days of abstinence from alcohol and any other drugs or alcohol. I'm proud of this. I'm a little ashamed to admit how proud I am. For eight years I've picked up my little gold coins and gave a little speech after my friends in the fellowship called out "tell us how you did it!" It feels good. But this whole thing, even at its hardest, was easier for me than it is for most people and those little gold coins are really just for show. Those coins mark consecutive abstinence, but abstinence is not recovery.

Mistaking abstinence for recovery is like mistaking a hammer for the house it was used to build. It's a mistake I've made, it's a mistake built into the policies of most treatment centers, and it can be a dangerous mistake for those who come to us for help. While a hammer is a useful, maybe even a necessary tool for building a house, it doesn't mean you have to start over just because you lost it for awhile.

I also don't believe that recovery and abstinence necessarily happen simultaneously. For instance, my recovery didn't really begin until I had been abstinent for almost a year, but since becoming a chemical dependency counselor it is quite common for recovery begin long before a client's last use. But whenever it begins it's important to remember that sustained abstinence may goal, but it is not the goal. A carpenter's dream isn't just to own a hammer, it is to build with that hammer.

Until next time.