I’ve been trying to write about the problems with substance use treatment in the US since I quit the field in November but haven’t been able to. I’ve been so burnt out from the topic that I even removed songs about drug and alcohol use from my MP3 list. Before I got a job at an outpatient substance use clinic about four years ago, I never had any interest in the subject. I was never interested in trying illegal drugs. I’ve never even smoked a cigarette. I have the occasional drink, but always stop at one drink per evening, and the only time I deliberately tried to get drunk was during my bachelorette party, and I really didn’t succeed because I didn’t like the feeling of being buzzed and stopped there.
The only history of substance use disorder in my family is my great-grandfather, who I never met.My parents don’t drink, not for moral reasons but because my dad, the pickiest eater of all time, just can’t stand the taste of alcohol. Aside from contending with asthma attacks triggered by second hand smoke, substance use did not affect me or my family growing up. Because of this, all of those contentious political questions about substance use that get everyone else so fired up didn’t interest me. As opinionated as I am, I didn’t have any opinions about legalization or 12 steps groups. I didn’t know enough or care enough to have an opinion about them.
Four years later, and I maintain that all of the issues are more complex than either side makes them out to be. But one thing I believe most people can agree on is the state of substance use treatment in the US is in shambles. NPR had an article about it today that just barely touched the tip of the iceberg.
So what do we need to do to improve substance use treatment in this country?
- Ditch the 12 Step Model and move to more evidence based techniques. OK, Alcoholics Anonymous and Narcotics Anonymous works very well for some people, but it does not work for the majority of people with substance use problems. Further, there are several aspects of these programs that conflict with modern findings about substance use and are dangerous for people in recovery. For a complete break down, see The Sober Truth.
- Primarily, the people providing treatment are LCDCs. LCDCs are poorly trained and tend to be in recovery themselves. I am an LPC and went to school for 6 years, have a Masters, and can treat the whole mental health spectrum. An LCDC goes to school for two years post high school at most (some with just a high school degree are grandfathered in, and the ones who tend to work in jails just have a certificate). They can only treat substance use, yet as substance use tends to be co-morbid with other disorders and, face it, substance use IS mental health, there’s a lot they can’t address. Further, counseling is more than just listening and giving advice (in fact, if your counselor is giving you advice I’d recommend finding a new counselor). And the sessions lead by and LCDC that I’ve set in on were not counseling. Some were cringe worthy. And further, a lot, but not all, LCDCs have serious mental problems themselves. There was one I was training when I was about to go on maternity leave in a week, and I had to tell my boss there was no way I could leave my clients with her. The least harmless thing she did was, when I gave her a list of referrals that I give to clients for case management purposes, she went to live at one of the women’s shelters listed. Knowing that we send clients there. Can you imagine going to live at a shelter and finding your counselor living there?
- As the NPR article addressed, the pay is poor. Especially for what the counselors have to deal with. People who go to substance use treatment are often forced into it. In our case, most of our clients have had their children removed by Child Protective Services. So we’re dealing with people feeling a lot of grief and shame because they lost their children AND who are in withdrawal. Some people come in very eager to cooperate and put their best face forward. Others, I can’t begin to describe the depths of their anger. Maintaining your cool and helping them to defuse that anger is draining. $40,000 a year does not begin cover the mental toil this takes on a person after awhile.
- The burn out. I was aware I was burnt out, but I wasn’t aware of just how bad it was until I got away from working there. And in my case I will say my boss did a lot to help us manage burn out. It’s why I lasted there as long as I did. We had work retreats about once a year. Last year, though, the Monday after my work retreat I spent an evening on the phone with a suicidal client who would not tell me her location (I did successfully talk her down). All of the relaxation I got from the retreat was undone by that Monday and I was even worse than before I went on the retreat. Suicide calls are emotionally draining and extremely anxiety provoking for counselors because we’re put into a confidentiality trap (if we break confidentiality and call the police, we could be sued successfully and lose our license, but if we don’t call the police and they kill themselves, then we can also be sued successfully and lose our license). Add to it that I, like most counselors I know, struggle with anxiety, it put me in a real bad spot. Really I think there needs to be a counselor contracted with clinics that counselors who work there can go to free of charge. The other thing my boss wanted to do but she could never get the staff to do it was have a counselor rotate among the staff so the counselors could have a break to develop curricula or do research or something else, but have a break from working with clients while still doing work vital to the company. I think having these role changes would have helped. And here’s the thing, having counselors who are energized and clear headed helps the clients. So it is vital the make sure the counselors are kept emotionally healthy.
- Increase the length of stay for people in treatment. It takes time for the brain to heal from substance use. Outpatient programs are about three months long. When a person stops using drugs, one of the times they are most likely to relapse is three months after getting clean. See a problem? Further, a lot of the times the problems a person coming in for treatment faces are so complex it’s going to take a lot more than three months to fix.
- Get as much of the family in treatment as possible. When one member of the family has a problem, the whole family has that problem. A lot of times I would feel like I put a fish in the bag, taught it some nice coping skills, and then threw it back in with the sharks. People with substance use disorders tend to come from families who have problems with substance use. Very few of them are willing to say good bye to their family forever or to tell them they can’t use drugs around them. So that individual completes treatment, and most of the time I think they genuinely believe they will be strong enough not to use around their family, and then BOOM, they’re back in treatment.
- Evidence based treatment, evidence based treatment, evidence based treatment. This means cognitive behavioral therapy. This means accepting that medication may be useful for some people rather than treating that medication as another addiction. However, it also means not going the opposite extreme and expecting to give a pill as a solution to every problem (as I said above, the reality is more complex than any side would maintain). Here’s what we do know, though. Addiction is not about will power. There is a biological competent. There are maladaptive thought patterns. A person’s environment plays a strong role in whether or not they will relapse. Good treatment needs to take all of those factors into consideration.
OK, that’s all I can do about this topic today. May be in another three months I’ll write more.