A call for sober reflection on addiction

To fellow health professionals,

Over the course of working in community care, I have seen the ravages of addiction. The substance itself damages the body, mind, and spirit when misused or accompanied by adverse experiences. There are negative impacts on the family and the social environment. Often, these impacts are felt through events that transpired while under the influence of a substance or while experiencing withdrawal from those substances. Financial resources are also drained by addiction. As a health care provider, we may not be directly addressing the substance use. Our role might seem like we are there to only provide adaptive aids to the client or strategies for managing their other health conditions. The addiction looms large, though, and can be the elephant in the room.

So how can a professional be of service to someone who is presently or formerly immersed in the world of substance use? These substances may have essentially destroyed their lives. We often go in with a set of tools that may confront our client in ways they are not yet ready to face.  Persisting in our therapeutic plans may trigger our clients. This could lead to emotional dysregulation. Trauma that is sustained throughout the years of use and after could be a factor influencing their current behavior and beliefs. As an Occupational Therapist, we must first approach the scenario with detached compassion.

Compassion means something different for each individual. Perhaps some people have never experienced compassion in any consistent manner. That may be why trust is not always present with the health professionals they work with.

Some individuals have met compassion in different contexts. Some within their families, others not. Some within their churches or religious systems, others not. Some within their schools, others not. Some within the healthcare system, others not. It is important to identify where this person may or may not have experienced compassion in the past. It can tell us a lot about how the individual will experience our compassion.

Why? Perhaps learning new things was associated with reprimands and punishment in the context of a school or educational institution. It is possible that proper attachment was never formed with parents or guardians due to abuse. Perhaps the last time they went to the hospital, they were told they couldn’t leave because they were deemed a danger to themselves. Some individuals have very good reasons not to trust these social and institutional systems. Not everyone will wish to divulge the existence of these personal traumas. Or they fear that the information could get used against them over the course of their interactions with the health professional.

How do we show sincere compassion? It is through an approach where we meet people where they are at. The understanding of how far along a client is in their recovery is elaborated on in the theory of the Stages of Change by Prochaska and DiClemente (1983). This theory is widely integrated into SMART Recovery programs and Motivational Interviewing. Some individuals will just not be interested in the conversation about goals related to substance use if they are in pre-contemplation. Or perhaps they struggle with maintenance and feel guilt about slipping backward in their recovery journey. Recognizing feelings and emotions that emerge for yourself and the client during each stage is our role too. Reflecting these emotions can be incredibly powerful and may not be something that your client has ever experienced compassionately.

Treat your client with the utmost respect for their journey, no matter how far along they are in recovery. Does that mean covering or enabling problematic behavior? No. In fact, the therapist respectfully directs someone to the proper resources to ensure that they take appropriate corrective action for their behaviours. Sometimes, the guilt of their past missteps is the barrier to their growth, creating a mental prison for them not to make progress. This could be supported with social work, the John-Howard Society, the Elizabeth Fry Society, the child protective services, police, legal clinics, lawyers, or psychiatric services. Having these resources in your back pocket is key to ensuring that you do not have to confront this issue alone. We mustn’t take on the mental prisons of our clients. These resources may or may not be taken up by the client. It is still our duty to ensure that the public remains safe and to complete appropriate reporting if there is a concern. Most of our clinical managers should be able to support this follow-through. However, some may not be equipped to do so and we should seek guidance through our college. Risk management must be addressed in these situations.

Respect can be shown through our interpersonal skills, offering to support a client in a way that shows we can bridge a gap in the healthcare system (i.e. communication with their family doctor when they failed to obtain needed prescription but feel guilt around non-adherence to medical advice) and maintaining clear boundaries when impulsive or limit-testing behaviors emerge. Respect and consent need to be maintained in both directions. Understanding the treatment can end based on either party’s discomfort within the relationship is key. This enables appropriate referrals and should not be looked at as a failure for either party. The therapeutic relationship that has to end is a lesson. Both can grow from the lesson. Release this attachment (imagine cutting a cord between yourself and them), acknowledge the emotions as you detach and reflect on what it says about yourself in a constructive fashion. Use the experience to improve your strategies for future therapeutic relationships.

As a healthcare professional, you possess a great deal of authority in these relationships. This authority can promote the client’s care, change and growth. Or it can be mis-used and, worse, abused. Abuse of individuals with addictions is rampant in our society. They are in extremely vulnerable positions in a variety of social contexts, especially when their use of substances leads to a loss of consciousness or significantly altered states of awareness. It is easy to misunderstand the actions, beliefs and perspectives of someone who suffers from addiction. Their memories or recall can be affected, making stories of victimization difficult to follow or missing vital information.

Their past actions can often be used as ammunition to create power struggles or take control over their lives. Be mindful of the weaponization of their addiction by yourself, other healthcare providers, family members or others in the client’s social network. This can be in the form of abuse of the role of power of attorney, hospitalizations or inappropriate actions taken by staff members in residential contexts or shelter facilities.

One form of weaponization of authority is through breaches in confidentiality. The effect of these breaches can go unnoticed to the professional. These inadvertent slips during casual conversations have a disproportionate impact on our clients. A comment to the wrong individual can lead to weaponizing vulnerability for someone’s advantage (via financial abuse, human trafficking, sexual exploitation, emotional blackmail, isolation or changes to services). Know when it’s time to bite your tongue. Discern for yourself whether something said about your client is in fact the truth before assuming that it is. Perhaps there was a misinterpretation or another perspective to consider. Gossip can breed humiliation and shame. Suicide or accidental death due to overdose is a crisis we are currently facing.

We must strive to make sure our profession is not perpetuating discrimination and injustices towards individuals with addiction. They come from all backgrounds, religions and social classes. Even with seemingly high-functioning clients, we cannot dismiss the role their addiction can play in their lives. Addiction can happen to anyone. Recognize that someone who is saying they are being persecuted by a group of individuals or a system may actually be targeted. Real persecution is not psychosis. Consider that the co-dependent/abusive relationship the client is in could be a source of a self-abandoning belief system that they are completely unaware of. Consider also that an individual’s past trauma could be the reason for the emotional dysregulation and trust issues you witness, and may not be a personality disorder. O.T.s do not have the power to make these diagnoses, and we should not mislabel the experience of our clients either. Mislabeling can create stigma and fuel a self-image of brokenness. Our role is instead to build up a sense of self-worth.

As health professionals, we should be consistent with our delivery of care. A meeting may be cut off by altered states of consciousness (therefore, informed consent is impossible) or frequent cancellations. If our practice cannot accommodate and set appropriate guidelines to structure our services for the client, maybe another service will. We should not give up hope on these individuals. Recovery happens and is beautiful to witness, but sometimes we are just a small part of that journey. Strive to be a positive experience of the healthcare system along their recovery pathway, no matter if it’s a straight line or goes around in loops.

Some of us have our own experiences using and/or abusing substances. These experiences colour how we treat others in these circumstances. We are not there to enable dysfunctional behaviours, nor are we there to judge their experience. It is natural to feel the need to compare our journeys to our clients. One must be careful not to burden ourselves with it either. Learning from others is an incredibly powerful way for us to grow. We must maintain enough detachment not to project our own experiences onto the client. Perhaps we need to seek help for our use too. Going down a path towards sobriety can improve our practice and can increase our clarity about the struggles our clients face.

When people have used substances to soothe the impact of societal failures, we need to recognize our place in society, too. Remind yourself you are not above the power of an addiction. It can be deadly. Maintain therapeutic relationships with compassion, reliability, and consistency while practicing appropriate detachment and boundaries. This population can challenge us in unfamiliar ways (if these challenges are unfamiliar, recognize you are in a position of privilege). Surround yourself with a team of trusted professionals who can discern the client's needs, growth potential, and the ways that their social, physical, and institutional environments impact their behavior. Recognize that not all those in positions of authority will have the client’s best interest in mind. Though we often face barriers to helping these clients, we must treat the individual with the compassion you would hope to receive if you were in similar circumstances. Continue to grow and evolve. Most of all, remember the battle our clients face to do the same.

Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51(3), 390-395. http://doi.org/10.1037/0022-006X.51.3.390