Heroin Has an Image Problem

Heroin has an image problem 

The most significant factor in the epidemic of opiates related overdose deaths has nothing to do how strong it is. Yes strong dope can kill you especially when it's laced with one of the many horror show opiates being manufactured overseas and shipped here but opiate overdose is survivable. Even if you don't have a Narcon kit (and if you don't shame on you) a person who overdosed can be kept alive a free from significant brain damage with simple rescue breathing. With Narcon you can have a person up and talking to you within minutes and there is more Narcon on the streets and people trained to administer it yet the bodies continue to pile up. The news feeds us more nonsense on how strong the new synthetic on the streets is and we all gasp and tut tut every now and then someone floats some asinine idea like forcing opiates addicted people into detox and possibly rehab.

http://www.rehabs.com/doing-time-should-we-force-people-to-get-clean/ 

An idea which is almost certain to increase the number of overdose deaths yet people both in and out of the recovery field jump on board screaming "it's about time" completely ignoring the fact that there is no evidence this will work. I can't blame them really. It's an outcry of people who are watching friends, loved ones, and clients die who desperately want to regain control but it is an illusion of control. Forcing people into a 72 hour detox will undoubtedly raise the body count. Opiate tolerance drops dramatically in three days and a daily heroine user freed after three days despairing for some relief is at very high risk of taking too much. But again it's less about how much the individual takes and more about where the person takes it. Not wanting to disappoint family or risk another 3 day incarceration the individual will likely shoot up alone. Opiate overdose happens quietly and the person will likely appear to have fallen asleep. In the dark no one will notice that the person has stopped breathing, that their lips are turning blue, not until it's too late. Narcon doesn't do a thing when it's in your sock drawer and your son or daughter is dying in an alley. There is a solution. Have them shoot up in your home where you can see them. If that's too much for you we can build clinics for safe injection and even supply the heroin so we know it's safe. This isn't a liberal pipe dream it's been and is being done and the success of such places would drive a call for legalization and implementation of these programs if not for one thing. Heroin has an image problem.

Most other drugs have an iconic image attached to them that is in part or completely positive. Marijuana has the harmless hippy or the cool Rastafarian, cocaine has the driven business man, and booze which kills more people and has always killed more people than heroin and is an epidemic all it's own with deaths from alcohol related diseases rising over 30 percent from 2003 to 2014, booze we tell each other to drink a glass at dinner because "it's good for you." But heroin and people who use it must be stopped. Heroin is so bad we are telling our doctors to stop treating pain and forcing people into programs that increase their risk of death because just sharing a world where people use heroin is simply unacceptable. It probably has something to do with the needles, the needles creep people out, but it probably has more to do with the question of who we think does heroin. The answer is of course "other people" and as long as we continue to believe that no grave digger will go without work.

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.

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

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.

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.  

 

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

My New Problem With Old Words

My New Problem With Old Words

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.

There is a movement to change the terms used when talking about addiction both professionally and in the media. I support this movement, I believe its premise to be correct. Words are powerful and positive and negative words have positive and negative effects on my clients and on myself as a person in long term recovery. This is not in my opinion, political correctness out of control. This is about improving outcomes for some of the most vulnerable people in our society. This is treatment on the largest imaginable scale and while all change is difficult and change on this scale is even more so, I find resistance in surprising places.

The most ambitious goal of this movement is to eliminate the words "addiction"  and "addict" from professional vocabulary. In theory this shouldn't be too hard, "addiction" is nether a scientific term nor is it a medical or psychological diagnosis. The main reason for this is there is no agreed upon definition of the word. Calling someone an "addict" never made any sense if you follow the disease model. A person suffers from cancer, a person is not a cancer (outside of the astrological meaning) Someone is never called a cancer due to a medical diagnosis and being called an addict is never a compliment. At this point you may wish to ask "If you think these words are so terrible Ken, then why have you used them in every Grey's Recovery post?"

It's a fair question. The truth is it bothers me. I can name several reasons for my choice of words, but the biggest and simplest reason is so that people understand what I'm talking about. The term "Substance Use Disorder" is what I use in clinical notes, but nobody knows what I'm talking about outside of the mental health field. Even in my professional life, in individual sessions and groups I use the word "addiction" and refer to people in general and to myself as "addicts." I get tired of constantly educating clients about terminology and getting diverted from what I see as more important topics. Also I don't want to seem judgmental or paternal by constantly correcting clients language.

 The second reason is something of an excuse, but the first is just laziness. I predict this change will be a long time in coming, longer perhaps than similar changes spurred by the civil rights, women's rights and the LGBT rights movements. In those movements it was the marginalized and oppressed population which demanded then drove the chance in terminology. In my experience so far it is the people in recovery from Substance Use Disorders who have been the most resistant to this change. Myself included. I've identified as an alcoholic or addict for eight years, I've found comfort and community in this Identity. But I think it's time now for a new identity. With that I would like to introduce myself. My name is Ken and I am a father, a husband, a chemical dependency counselor, and I am in long term recovery. 

That's enough change for today.

"I freed a thousand slaves I could have freed a thousand more if only they knew they were slaves." Harriet Tubman