Substance Abuse

This subject can be controversial. Treatment for substance abuse is generally: "Wait until they hit rock bottom (jail, OD, hospitalization, losing everything, etc.), use motivational interviewing until then, send them to detox, do some counseling and send them to AA". I know it is not everyone's opinion, but I am looking at the general view of the treatment.
Let's address this one by one. Let's get one thing out of the way: AA (Alcoholics Anonymous), NA, CA, or __A is NOT treatment. Do I believe in AA? Well, let me put it this way: I have seen it work for some people, I have seen people hate going there for various reasons (triggering, boring, too Higher Power oriented, steps are too complicated), I have seen it grow on people. I believe that AA has good intentions and it has help many people, but to put all individuals in the same boat is wrong. Think about it this way: When you have diabetes, there are several options for treatment, from diet change, to regular insulin, and everything in between. Self-help groups can be part of treatment, but it cannot be the only way a person remains sober.
Motivational interviewing is based on stages of change and meeting the person where they are at. The 6 stages of change, and yes there are 6, are: pre-contemplative, contemplative, preparation, action, maintenance, and relapse. At anytime, the theory is the individual is at one part of these stages. I work with stages, not cycles. I think that an individual can jump stages, fall back, stay "stuck" at one point or the other. Again, meeting as person where they are currently and making sure they get information they need at that time is the best practice. Oh, and yes, relapse is part of it. Relapse may bring you to a different stage, including maintenance. But to assume relapse brings you back to pre-contemplative is shaming.
Shame: what a powerful emotion. I think that most individuals who have a substance use issue have been through shame most of the time they have been using. Using shame in counseling is probably the worse thing you can do, unless, of course, you want the person to really fall back to pre-contemplative. A person goes through enough shame when this happen, why add to it? I think we need to work on looking for the strengths and how they can be used in order to get the sobriety goal met again.
The rock bottom theory: while in principal that is great, I believe that if you wait until then, you might not be able to help that person. Think about it: an overdose can be fatal or even cause permanent damage, a crime can lead to a lifelong conviction, etc. Why wait until then? Will they change before that? Who knows. But giving up  is not always the solution. I have worked with people who told me that I was the first person in a long time that actually asked them how they are doing and why they are still using. The "why" is usually the key. Some people believe some drugs are "harmless" (FYI, none are like that if consumed daily), some are too addicted and don't want to go through withdrawals or even detox, some don't know how to ask and others are tired of being told to "hit a meeting". Rock bottom is not good the answer.
As for detox, only certain "drugs" can be a reason for admission to detox (good luck getting a detox for marijuana) but most drugs lead to detox symptoms. Most of them do not lead to death but not being able to smoke may lead to increase anxiety, panic attacks, and feeling helpless. No physical addiction does not equate no detox symptoms. Most people feel misunderstood and also do not want to deal with these symptoms. Acknowledging those symptoms and finding ways to address them is the key when a person is stopping their drug.
As for maintenance, the use of medication assisted treatment (MAT) (suboxone, methadone) are extremely controversial. I believe again that you have to use a personal fit when thinking about these solution. Some people believe it is a legal high. Others see it as a crutch. And others swear by it. Again, you need to explore what will best work for you. If you are going to use MATs, I strongly encourage counseling (most doctors who prescribe these meds actually expect it). The doctor, the counselor, and the person using MAT should have open communication with no BS. And this is where I also differ: MATs were originally prescribed to help individuals get completely off all drugs, including these meds. But there is no money in that. The manufacturers of these meds, in collaboration with the doctors, now push a lifetime use of these meds. I strongly suggest that, if you use MATs, you should have an exit strategy, off the meds. These meds should not be substitute, they should be just a part of a long term plan.
Is counseling the only solution? Of course not. It is one of the solutions. But most experts agree that a combination of motivational interviewing with cognitive behavioral treatment is probably the optimal way to address these issues. However, it is not the only solution...Hope you get my drift.

Therapeutic Goals

It is usually one of the first questions I will ask or it will be one of the first statements of the person seeking therapy: the goal of counseling. As far as I'm concern, if this is not discussed right away, the first session can be a terrible disappointment  to both the client and the therapist.
Some people mistake the goals with the "why" of counseling. Stating that you are in counseling because of x/y/z really is not as important as "what do you want to accomplish?". Let me explain: someone may come to counseling because of others saying they are ______. Frankly, being in counseling for that reason is probably a) not a good reason to be in counseling and b)not the goal of the person seeking services.
If a person is coming to see you to confirm or infirm that statement, now we have a goal. Sometimes, however, they come to you for a total different reason. They may have noticed other things relates to that reason. A substance user may originally come to counseling because of others saying they have a problem but really, they feel misunderstood, have a short fuse, etc. Hence you can finally identify the goal of them seeking counseling.
It is not unusual that the original reason does not end up being the goal of the therapy. And that's ok. Most people can identify the why of counseling but, to many people, the goal is really the key to a successful first session and therapeutic relationship long-term.

Treatment Philosophy, Part 2

I wanted to add a few notes about my treatment. I believe that you got to meet people where they are at. What I mean by this is that if a person is motivated for change, we are going to talk about ways to change right now. If a person is unsure, then you work on  motivating them and see if they do want to change. The one thing I will not address immediately is past trauma. Why? I think it is irresponsible to work on it right away. You must develop skills and be sure that a person is ready to go there and have the tools to recuperate from discussing trauma. Therapy is only an hour a week but dealing with past trauma goes beyond the hour meeting. Give skills in order for the person to deal with possible thoughts about the trauma when the therapist is not there.
One of the first lessons I got from one of my favorite clients is that you must be real. People have been lied to, told stories, made promises, and had guarantees made to them in the past. Most of them turned out to be untrue or filled with conditions or "but"s. I think being as real as possible is what makes therapeutic alliances last. I am who I am and that is OK. I have some faults and I will always say that if I make only one or two mistakes in a day, that is an awesome day. We all make mistakes and we need to be honest about it. I expect that you will not come in perfect and I got to admit my mistakes when I make them. One of my favorite quotes from that same client is the following: "We can smell a phony a mile away". For the record, I still see this client in counseling.
If you read my blog, I disclose some information. I don't mind you knowing that. I also don't mind personal questions. I think they can be appropriate at times. I always remember the statement of one of my favorite singer. She said: "There is a difference between secrecy and privacy". Secrecy implies you have something to hide. Privacy is just normal stuff that is not kept secret, just some information that are private. If you ask me if I have a cat, why would that be secret or private? If you ask me where I live, well that is private. It's a line that can be blurry but I think that showing transparency improves the relationship with the clients. Making it about me, well that is wrong. I don't think everything about me should be secret but there are certain things that are private.
I also believe in the expression of emotions. Most people avoid certain emotions, especially some that are perceive as negative. I tell people to live their emotions, every one of them, as long as they do it appropriately. What I find is I have to facilitate the expression of these emotions. I think that if you live your emotions, you will feel more fulfill, more complete, and less repressed. I also like to make people feel uncomfortable. If you are having therapy and you are comfortable and you feel your therapist is on your side, you may not be getting everything you can from your therapist. I challenge, ask difficult questions, and make you feel like this is hard work. I think you need to challenge every client in order to earn your keep so to speak. Most of my clients appreciate it...eventually.