By Karen R. Koenig, LICSW, M.Ed.
Imagine this scenario. You struggle alone with a problem for years, perhaps decades, and finally get up the courage to seek therapy. You find a social worker, make an appointment (perhaps taking time off work or arranging for child care) and nervously arrive at their office. Face to face with a stranger, you answer a host of intimate questions and begin to dredge up your history, however painful. Sometime during the appointment, this social worker asks if your problem still persists or whether you have it under control. You’re confused. You thought it was clear that you couldn’t cope on your own - that’s why you’ve come. You’re looking for help, for support.
But instead of receiving hope and understanding, you are politely told that you’re not ready for therapy. First, you’ve got to get your problem under control. Then you can come back and talk about it. It’s hard to take in this message, but after all, they’re the expert; they must know what they’re talking about. So you pack up your problem and leave, berating yourself for seeking professional help in the first place. This scenario would never occur if a client suffered from depression, schizophrenia, bi-polar or anxiety disorder. Imagine turning away a client because he/she continues to fight with a spouse, binge and purge, cut themselves, or wash their hands obsessively. In fact, there is only one problem, one population I know of, whom we turn away from treatment solely because their problem persists.
That problem is, of course, alcohol and drug addiction, that population of the multitude of drinkers and drug-abusers whom social workers refuse to treat because they are what we call "actively using." The theory behind such denial is, I believe, as follows: we should not treat a client who is currently drinking or using drugs because we are wasting our time; our good work and their progress will evaporate with the next bottle, be obliterated by the next binge. When the client gets clean - in body and in soul - then, and only then, so the thinking goes, are they ready for therapy.
Having worked in the field of addictions in a variety of settings for some 20 years, the wisdom behind this treatment approach escapes me. Why do we treat clients with alcohol and drug addictions differently than those with comparable psychological/emotional difficulties? Is this refusal based upon collective experience, upon study and research, upon sound psychological theory? Or is it based upon mere bias and assumption which feels valid only because it is so widely shared by other professional disciplines?
It is perfectly clear why a social worker would refuse to admit to session a client who is intoxicated, high or even mildly sedated. It makes excellent sense to use limited time wisely and to set limits for clients who are unable to establish their own. An addicted client must be clear and lucid during the session, painful as that may be, for them to gain anything from the therapeutic exchange. And observing and monitoring which sessions the client chooses to attend under the influence may even give us valuable information about what disturbs them most.
It is no news that clients who suffer from and with addictions frequently lack essential emotional life skills. They may not be able to tolerate painful affect, set limits, maintain boundaries, self-soothe, ask for and accept help, set goals for themselves, articulate their needs, harness shame and guilt productively, contain destructive impulses, love and value themselves. The list of these clients’ emotional deficits is long and disheartening, and misguided attempts to patch their emotional holes with drugs or alcohol have only widened and deepened the cracks in their characters.
Therapy gives these clients a chance to reverse characterological damage and build true psychological and emotional capacity as they learn that sadness and grief will not kill them, how to say yes to what helps and no to what harms, to use shame and guilt as real deterrents to impulsivity not as after-the-fact self-punishment, that they are unique and irreplaceable in this world, and, perhaps most importantly, that they have the ability to love themselves and others and be loved in return. When these skills, which most of us take for granted, become integrated into the psyche and personality of the addicted client, only then do they have the psychological infrastructure to tackle their addiction.
Ironically, drinking and drugging are sometimes the last-or one of the last- behaviors to drop away from a retinue of unhealthy behaviors. And even after sustained abstinence, relapse into drinks and drugs is nearly inevitable. Relapse is an integral and necessary part of the recovery process, the equivalent of a psychotic client’s decompensation after they have stopped taking their medication. Trial and error is how clients - how we all - learn; there is no better way to teach cause and effect, action and reaction, recognition of the inescapable link between act and consequence.
Most of us, thankfully, will never know the immense efforts required to recover from alcohol and drug addiction. So many addicted people never even try to quit; of the number that do try, so few make it. This sad state should tell us something about the engulfing and enduring nature of the problem and may say more about our ability to treat it than about the labors of those afflicted. Addiction is a hard nut to crack, but with diligence and persistence, it will generally break open its fruit.
Those who are addicted desperately need the tools we have to teach them, the compassion we have to offer, the hope and ongoing help that is social work’s hallmark for treating chronic conditions. When we ask that a person struggling with addiction come to us straight and sober, we are singling them out unfairly. Would we tell someone suffering from psychosis to seek us out only after they are delusion-free, suggest that an anxiety-ridden person make an appointment when they have shaken off their fears, propose that someone on the verge of suicide come to see us when they have rediscovered the will to live?
When social workers refuse to treat actively drinking and drugging clients, an already scorned and alienated population is further stigmatized. Few are more in need of our help than those who chronically abuse drugs and alcohol. Most, though by no means all, of them will move closer to permanent recovery through treatment with us. It is time to open our minds and our practices, time to follow Lady Liberty’s example and welcome the actively addicted to our shores.
FOCUS Newsletter - September 2000
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