Like many other mental health treatments, substance use treatment has struggled with high dropout rates and problems with engaging clients. Only 0.9 percent of people who have some substance use issues engage in treatment. While some of this may be the client’s internal reluctance to get care, this may be systemic due to the lack of treatment options available.
Most treatment programs require the goal of complete abstinence from all substances. Some will not accept clients who are not committed to this goal. While this may seem routine, no other mental health field demands one specific goal defined by the agency as well as a front-end commitment to one goal. For example, people who are depressed do not meet intake clinicians who insist the person be committed to not being depressed ever again.
By a clinic setting the goal of abstinence, we may lose many people to ongoing drug and alcohol use. The message that people may hear is that I should not enter treatment until I am completely convinced that I should be abstinent from all substances. A common statement in substance use treatment is that a person “is not ready” when the question should be” what are they ready for?” The stages of change model has been helpful in looking at where people might be in terms of behavioral change. Our traditional treatment model insists that people be ready for action and does not leave room for people who are contemplating change. Programs might be able to help people in a preventive way by engaging people who are contemplating making a change but not ready for action with regard to their use.
The traditional treatment model also assumes the belief that people’s motivation for abstinence does not waiver and if it does, there is a problem. The theory is that once you are ready to commit to a goal you will always have that same commitment. As a director of a clinic, we have gotten referrals from programs where a client was just expressing ambivalence about their abstinence goal. For example, one referral was for a client who had been sober for 6 months from methamphetamine, their drug of choice, but was considering the option of drinking. This case seems like a success with the person building sober time but the fact that the person was thinking about drinking triggered a referral out.
When we create this context for treatment, we may be reinforcing the idea that motivation should never waiver. Clients may feel that they should not voice their ambivalence or they will be rejected. All therapists love to work with a very engaged, motivated client but part of the work is also helping these same clients build skills when they feel less motivated. Normalizing this experience may prepare people in the future. Motivation is a fluid process in our lives. If a person feels less motivated to maintain their goal of abstinence, they may judge these feelings as opposed to being prepared and having skills to deal with them.
When I first entered the field, programs often terminated clients if they relapsed a certain amount of times. Again, this message seems harmful in that we are dismissing people who are exhibiting the presenting problem. While people may need higher levels of care such as inpatient, there are often ways that people are making improvements in their lives which may not be reflected in their use. Some people are reducing their drug use or not using their drug of choice. Some are making behavioral changes that will lead to healthier lives. In addition, there are many clients who struggle to accept that they need more services such as medication management or inpatient and need time. There is an assumption that by dismissing them from treatment we are providing good care even though there is no empirical validation for this perspective.
This traditional model sets up a non-collaborative relationship between the therapist and the client where the therapist is the clear authority. When we set these goals for our clients, we make a statement that they are expected to progress on the therapist’s timeline.
As a provider who oversees many levels of care, I have assessed people as needing a certain level of care such as intensive outpatient treatment which a client may refuse. There are times where a client starts a lower level of care and does well. Treatment centers should engage people with what they are willing to do rather than reject them. Many treatment centers have a very specific array of services that they “fit” the person into. For example, some programs insist on initial intensive services regardless of the person’s presentation.
Our field tends to set up many ways of shaming and rejecting clients that often adds to the problem. There is so much internalized shame around drug users that it does not need to be reinforced by providers.
Substance abuse programs treat people with comorbid psychiatric issues and trauma histories but fail to acknowledge how this can make a person’s struggle to reduce harm more complex. A client’s history of abuse and neglect often shapes their attachment to the therapist. Building this therapeutic alliance is crucial in treatment as opposed to setting goals. In addition, many clients are self-medicating their psychiatric symptoms and it can be a process of building skills for this person so that they don’t rely on substances as much.
For many years now, there has been an ongoing ideological debate that actually has faulty logic and highlights the difficulties with the types of treatment we provide in the area of substance misuse. That debate is often titled, “harm reduction vs. abstinence.” However, a problem with this debate is that harm reduction includes abstinence as an option. Setting the goal of abstinence is a great way to reduce harm. Part of the problem is that people have such personal and ideological reactions to the use of words like harm reduction. They struggle to really listen to what it means. A greater investment in engaging clients by providing an array of options would increase our success in working with people who misuse substances. It actually helps the therapist see progress in a more complex way.
You may reach Dr. Joe Ruggiero at joseph.ruggiero@mountsinai.org.
