Making a Difference in the Lives of Individuals with Substance Use Disorder

LEARN MORE, PRACTICE DIFFERENTLY, AND FEEL CONFIDENT WORKING WITH CLIENTS BY JOINING US FOR A SEMINAR ON, “NEW STRATEGIES FOR SUBSTANCE USE ASSESSMENT,” ON FEBRUARY 20, 2019, 9:30AM – 4:30PM

“We would like to take things to the next level with Raj. He seems to be ready and motivated, though he thinks he cannot make it. We would like to build on the momentum.” Edward articulated these words to Rodis, a consultant to the HOPE ACT team, working with Raj, particularly Maryann and Edward himself.

This is the fourth article of the series, New Strategies to Working with Individuals with Substance Use Disorder. In the first two articles, I outlined ten benefits that derive from mastering and implementing the New Strategies to Working with Individuals with Substance Use Disorder (for details, see the two articles entitled, New Strategies to Working with Individuals with Substance Use Disorder: 5 Benefits; and “Addiction”: How to Work with Individuals with Substance Use Disorder.) In the third article entitled, 5 Ways to Serve Individuals with Substance Use Disorder, I described five key questions to ask.  In this current article, I am going to describe how we can make a difference in the lives of the individuals with substance use disorder.

“You have been learning and implementing the New Strategies to Working with Substance Use Disorder, in your work with Raj, with good results. You now want to take things even further to the next level. Let us discuss the additional five questions that will help you make a difference,” Rodis reported to Edward and his colleagues.

The first five questions, described in the previous article, help with establishing rapport, with joining in, and with understanding and formulating a plan. Once you have reached this point, it is time to go to the next step that will prepare you to problem solve. This step involves having a clear picture of the magnitude of the substance use, including the related consequences; assessing the stage of change for your patient and client; and discovering which barriers need to be overcome. Master these five questions and start making a difference:

Consequences of use

Some may be obvious and others may not be. Asking your patients and clients about consequences of use is a powerful tool, with an amazing ripple effect. It helps give you a better idea of the severity of the current use; it helps your patient and client sum up what he or she thinks the consequences of use are, and it also helps assess for the stage of change. “I had a good job with opportunities for promotion; I was in college for engineering, and I had a good girlfriend, Marla. I lost all of it. I have sought help, but I was always expected to “just be strong,” as if the picture of my mother being raped and killed in front of me, would just go away, just like that, by itself. I never had a chance to tell my story until now, but no one had bothered asking, anyway. I am tired of living like this. I want to stop using these drugs. They are not taking me anywhere good.” Raj expressed this to Maryann, with his head down and tears in his eyes. The answer to the question of consequences of use can help pave the way to getting to a commitment for change.

Comorbidities

Some places provide substance use treatment and neglect the associated mental health and other general medical conditions. Other places treat the general medical or mental health conditions and neglect the associated substance use disorder.

As stated in the first two articles in this series, we have been practicing healthcare in a silo, practicing fragmented care, and this has been to the detriment of our patients and clients.  It has also been of harm to us, as clinicians, to our agencies, and to the health system, as a whole.  Asking about comorbidities helps us circle back to one of the previous questions regarding the explanatory model of use for our patients and clients.

“I saw my mom being raped and killed in front of me, and I could not save her.  I have always hated myself for that and when those pictures come back in my head, I just cannot take it,” stated Raj, in response to the opportunity given to him to state his explanations and reasons for substance use.  While Raj did not say, “I had untreated PTSD as a comorbid disorder,” the description of his pain vividly presents PTSD for consideration.  “I have difficulty sleeping. I wake up in the middle of the night, screaming, trying to wake up my mom, lying on the floor, in the woods. I also had two small heart attacks and the doctors told me they are from cocaine.”  Caring for the patient and client with substance use disorder is no small task.  It is no wonder so many of us develop such strong countertransference and biases against them.  But it does not need to be this way.  With the mastery and implementation of the New Strategies to Working with Individuals with Substance Use Disorder, you will have the required tools for making a difference in the lives of your patients and clients.

Sense of self

As I once described in a previous article entitled, 5 Tips to Help Engage Your Patients and Clients, Jay, a 21-year-old male, after six months of remission from Opiate Use Disorder, told me, “Now that I don’t use, and I don’t hang out with my old friends, I don’t know who I am anymore. I don’t feel like I belong anywhere, because all I knew was being an addict, since using when I was age 14.”

Asking our patients and clients about their sense of self helps us identify, early enough, barriers to treatment, to sustained sobriety and ways to prevent relapse. “I don’t really think I can. I don’t think I can make it.  I want to stop, but I honestly don’t see how this will be possible,” said Raj, when asked how he felt about himself.

Take some time to ask your patients and clients about their sense of self.  And, when you hear something like Raj’s response, make sure to prioritize restoring a sense of self in the treatment plan.  For many, other interventions may be to no avail unless you help restore their sense of self.

Stage of change

Stage of change is related to sense of self in that it helps you meet your patients and clients where they are at.  The answers to the question regarding consequences of use can also give some hints to the response to the question related to stage of change.  Furthermore, asking your patients and clients about this requires a combination of art and soft skills.

“I had a good job with opportunities for promotion; I was in college for engineering and I had a good girlfriend, Marla. I lost all of it,” said Raj.  With this answer, instead of a follow up question, wha is first needed is a validating or reflective statement like, “You seem to be saying that there have been some consequences and some problems related to your use, and something needs to change.”

This implies that Raj is beyond Pre-contemplation, the first stage of change.  However, during exploration of his sense of self, Raj also said, “I want to stop, but I honestly don’t see how this is going to be possible.”  Once again, instead of a question, what is required is a statement like, “You believe there is a problem but you do not think there is a solution.”  With this, Raj would belong to the Contemplation phase and short of the Preparation phase, not because he is not ready to change, but, rather, because he does not think he can change.  This knowledge will help the team focus first on restoring his sense of self. (Refer to the published SWEET book, entitled, “Discovering Your Worth: Everything You Need to Feel Fulfilled” for additional tools on this)

Purpose and meaning

In a previous article, entitled, In Search of A Purpose, I stated that, according to the Cambridge English Dictionary, “Purpose” is defined as the reason for doing something or for allowing something to happen; and that living life with purpose means making the conscious decision to understand your life, to consciously evaluate the “why” of your life and deliberately live and strive towards it.  In that article, I also explained that if you currently feel like you have no clear purpose or have lost it, or stopped living it, then, at best, you may experience an unhappy life with little meaning, and at the worst, you will likely experience a constant, incessant and insatiable pursuit of happiness.  This could unfortunately lead to addictive behaviors and to an increase in physical illness, mental illness, and even suicide.  The loss of purpose may take place after a major loss, a crucial setback, or a traumatic event, as in Raj’s case.

Also, I continued on and discussed some of the benefits of living life with purpose.  I described that a life with purpose helps keep vision in mind; it sets your destination path, which in turn keeps you motivated and makes it easier for you to withstand life challenges.  I added, too, that living life with purpose also forces you to become more self-aware, to be more deliberate, and to make more conscious decisions.  I cautioned that this might sound challenging, difficult, and even impossible, at times.  Where it may sound onerous, and it can be, it is also doable, and the process of getting there is an important part of self-discovery.

By the time you have finished reading these two last paragraphs, you might be wondering, not less than one time, what does purpose, or meaning, or life with purpose, have to do with making a difference in the lives of individuals with substance use disorder, or with New Strategies to Working with Individuals with Substance Use Disorder?

Let me explain.  While the rate of substance use disorder is higher in physicians than in the general population (10-15% versus 6-9%, respectively), the recovery rate is higher compared to any other group (at least 80% and much higher in other studies).  The question is why such a high recovery rate among physicians?  One of the most recurring themes is purpose and meaning. Physicians have spent years of sleepless nights, and they have done all this with a purpose. As a result, once this purpose is significantly threatened, they will likely do whatever it takes to safeguard it.

The next time you meet with your patient and client affected by substance use disorder, ask him or her, “what gives you purpose, and what gives you meaning?”  Whether your patients and clients know the answers or not, you can work with them on either finding or restoring their purpose.  The two articles entitled, In Search of A Purpose and Finding Your Passion include guides you can use to work with your patients and clients.

“I tried to kill myself several times and I am still alive. I believe I am here for a reason. I don’t really know why, but I would like to know,” responded Raj to the question regarding his purpose.  Edward, Maryann, and the rest of the team are taking steps to start working with Raj on finding his purpose and passion, while connecting it with his sense of self, harm reduction, and treatment for his symptoms of trauma.

Maryann and her team started by not knowing what to do with Raj.  After consultation with Rodis, they have came to realize what they did not know and made the decision to learn the New Strategies to Working with Substance Use Disorder and implement them.  Now, they have been seeing good results.

LEARN MORE, PRACTICE DIFFERENTLY, AND FEEL CONFIDENT WORKING WITH CLIENTS BY JOINING US FOR A SEMINAR ON, “NEW STRATEGIES FOR SUBSTANCE USE ASSESSMENT,” ON FEBRUARY 20, 2019, 9:30AM – 4:30PM

References:

1. Drake, R. E., McHugo, G. J., Clark, R. E., Teague, G. B., Xie, H., Miles, K., & Ackerson, T. H. (1998). Assertive community treatment for patients with co-occurring severe mental illness and substance use disorder: A clinical trial. American Journal of Orthopsychiatry, 68(2), 201-215.

2. Weiss, R. D., Greenfield, S. F., Najavits, L. M., Soto, J. A., Wyner, D., Tohen, M., & Griffin, M. L. (1998). Medication compliance among patients with bipolar disorder and substance use disorder. The Journal of Clinical Psychiatry, 59(4), 172-174.

3. Barry KL, Fleming MF, Greenley J, Widlak P, Kropp S, McKee P: Assessment of alcohol and other drug disorders in the seriously mentally ill. Schizophr Bull 1995; 21:313–321.

4. Lehman AF, Myers CP, Dixon LB, Johnson JL: Detection of substance use disorders among psychiatric inpatients. J Nerv Ment Dis 1996; 184:228–233.

5. Regier DS, Farmer ME, Rae DS, Locke B, Keith S, Judd L, Goodwin F: Comorbidity of mental disorders with alcohol and another drug abuse. JAMA 1990; 264:2511–2518.

6. Ananth J, Vandewater S, Kamal M, Brodsky A, Gamal R, Miller M: Missed diagnosis of substance abuse in psychiatric patients. Hosp Community Psychiatry 1989; 40:297–299.

7. Wolford GL, Rosenberg SD, Oxman TE, Drake RE, Mueser KT, Hoffman D, Vidaver RM: Evaluating existing methods for detecting substance use disorder in persons with severe mental illness, in Book of Abstracts, 1996 Midwinter Meeting of the Society for Personality Assessment. Falls Church, Va, Society for Personality Assessment, 1996.

8. Drake RE, Yovetich NA, Bebout RR, Harris M, McHugo GM: Integrated treatment for dually diagnosed homeless adults. J Nerv Ment Dis 1997; 185:298–305.