Back to Basics

So what really drives our clinical decisions in the field of addiction? How do we end up ascribing to a particular clinical philosophy, therapeutic approach, or modality? Our graduate education, early career mentors, and entry level experience could definitely have played a major role in our professional identity. But at the same time, we must go back to basics and ask the fundamental questions that have profoundly shaped us as addiction professionals.

These fundamental questions are:

1. What do I think addiction is?
2. How do I think addiction develops and is maintained?
3. How does one recover from addiction?

Those entering the field as university students hold ideas in regards to their answers to these questions. It is also important to consider the prevalence of individuals in recovery themselves who enter the field of addiction treatment. They have their answers to these questions as well. And sometimes, these answers are held with strong conviction.

We know that the answer to these fundamental questions could have been informed by society, by family experience with addiction, by personal experience with addiction, and by media exposure; all these, even prior to any formal education on the topic.

A common pathway for those entering the field is to ascribe to a therapeutic approach or modality that validates their pre-existing answers to the fundamental questions. We can be quick to cherry pick research findings that support what I already knew. And this is OK. You would want the work you do to be aligned with your personal beliefs. In this sense, the person is attempting to reduce cognitive dissonance.

We could imagine the differences in answers to the fundamental questions between a professional that believes in abstinence based recovery versus one that believes in harm reduction. Between one that believes in an acute model of care versus one that believes in long term self-management.

As one progresses through their professional development, one could be encountered with diverse therapeutic approaches, shifts in society’s view, a supervisor that will push the envelope in a different direction, new research, and maybe a different job that implements a different clinical philosophy. The one constant is change.

Can I allow my answers to the fundamental questions to grow and change over time? Do I still believe addiction is the same concept I believed in 20 years ago? Do I still believe people recover in exactly the same way as how I thought when my career began? Or am I changing and evolving my views?

How we remain open minded and are able to embrace this change becomes a necessity in our fast-evolving world. Not only for our professional sake, but more so for those we serve. At the end of the day, it becomes a question of ethics.

This is not only an addiction professional issue. Those we serve, our clients, are also fellow travelers in this journey. They also present themselves to the treatment episode with answers to the fundamental questions of what they believe addiction is, how it was developed and maintained in their specific cases, and what they could do to recover. The answers to these questions are not always overt or ordered neatly in their minds, but even in cases as such there are underlying beliefs about these issues that directly affect their engagement in treatment.

The work that I can do as a helping professional in understanding the client’s answers through their perspective can go a long way in the development of the therapeutic alliance and in a positive outcome. How flexible and adjustable I can be as the professional is key. For this flexibility to seem authentic as it translates to a helping relationship, I must have been witness to diverse experiences that can enrich my capacity for multi-level empathy.

As you close your eyes and reflect, how can you answer what addiction really means to you today? How do you think it develops? And how do you think people really recover? The answers really matter to what we do as helping professionals and to those that seek our help.

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Ohhh noooo!! It’s a difficult client!!

So how do we react to the difficult inpatient client in our caseload? That person who acts defiantly, does not comply, seems that does not want to be there, but is. Other peers in treatment are not too keen of this client and neither is staff. Does the client follow programming? Not quite.

This scenario presents a challenge to clinicians, staff, and others participating in treatment. The client behaves in such a way that gets under everyone’s skin but is not doing enough to have their treatment terminated. Every morning the news on how clients are doing revolves around this specific person. Whaaaat now? What did the client do (or didn’t do) this time?

How is the psychic and morale of the clinician affected? Do we wish this client wasn’t here anymore? Can insurance please deny further coverage? Can we just kick this person out?

Helping the client engage in treatment can be a work in progress while meeting the client where they are at can also be challenging without the support of other staff who want you, the primary clinician, to “fix the client”. Wishing this client not be in treatment can seem like the best out, but many dynamics must be addressed if we are to remain true to the importance of patient care and ethical practice.

In an individual sense, the clinician must be aware of feelings arising from the situation, be it transference related or due to pressures from others involved. In group settings where staff is present discussing the case, the clinician must be aware of how others’ comments affect their own perspective of the situation and of the individual. Are we buying into the groupthink or are we able to maintain our individual opinions?

They all deserve the best from us, always and unconditionally, whether we like them or not, independent of our opinion, and independent of our professional prognosis.

The need for supervision seems paramount in cases as such. Easy answers should not be expected as there are many factors to consider. But if we are to speak about client care and ethical practice as a priority, the following points are of relevance:

While the client is still in treatment and under our care, this person deserves nothing but the best from us and our team. That is the warranted client care. The possibility of assessing whether the client should be in this treatment episode, or not, becomes a different conversation. Until, and if, a decision as such is made, the client is still a client, no matter anything else.

Am I as a clinician aware of the power of my expectations of the client, on the client’s outcome? There is a chance of closing down possibilities to be helpful if my expectations of this client are minimal or non-existent; if I am not as present as I can be for this person; if “I know this client will fail, so why try”. They all deserve the best from us, always and unconditionally, whether we like them or not, independent of our opinion, and independent of our professional prognosis.

Picture this scenario: I take my car for a tune-up, but I am not one of those to really take good care of the car nor to follow all preventive care suggestions. It is also a bit dirty and filled with fast food reminders. How would I feel if I found out I was not given “the usual tune up” they give everyone else because the mechanics thought I did not deserve it for not taking good care of my car? I did pay the same amount as the “worthy ones”. I don’t know about you guys, but I would not be a happy camper.

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