Written By Jeff Brosnan, MA, LMFT (MFCC#49984)
A Client once said to me: “My addiction to Crystal Meth is my own best friend. I know what I will get from getting high. Crystal Meth is not like some people I know who let me down time and time again.” Wow. I sat there and thought to myself, how am I going to respond to that?
Wouldn’t it be great to hand someone a pamphlet or a book and give them instructions to just follow what is written and they will remain clean and sober the rest of their lives. How about a pill that will remove all cravings for any and all addictions, and the pill would be very inexpensive? I could have recommended Crystal Meth Anonymous (CMA) meetings. I could have recommended an inpatient or outpatient program. An MD or Clinic for a full work up. A Psychiatrist for a consultation.
I remember studying for the BBS Licensing Exams and it being drilled into my head to refer out to adjunct services, especially if the issues raised in therapy were out of our scope of practice or scope of competence. That all makes sense. Let’s get back to our Client and see what we can do right now.
1) Mandated Reporting
First things first. Check for Suicidal Ideation, Homicidal Ideation, Elder Abuse, Child Abuse and Dependent Adult Abuse. Things to check: Who they live with? Ages? Are any of those who live with them addicts, too? Is anyone besides the Client in harms way? Report if necessary.
2) Are they Clean and Sober Right Now?
If they are Clean And Sober right now, in the therapy room, great. If not, you have a choice to make whether or not to continue the session. At this point, if not already discussed when reviewing Informed Consent documentation and conversation, you have the opportunity to iterate or re-iterate your sobriety rule: It could be along the lines of being clean and sober at least 24 hours prior to and post therapy session and the reasons why.
If the Client is not clean and sober in the therapy room and whether or not you choose to terminate the session it is of the utmost importance to know how they got to therapy–public or private transportation. If they drove to therapy you may want to recommend they call someone to drive them home, or, if no one is available, offer them a telephone number of a local taxicab company and observe them calling for a taxicab.
Your Session Progress Notes need to indicate the steps you took regarding keeping the Client safe.
3) The Client is Currently Clean and Sober
The Client showed up. The Client is currently Clean and Sober. The Client indicates they want help with their addiction. Now what? There may not be a lot of time left in the initial session to fully explore the issues surrounding addiction. This may be a good time to ask the Client about the times they have been successful in remaining Clean and Sober and for how long?
4) Construct Two Timelines
Take out a fresh unlined piece of paper and draw a timeline of times in the Client’s life he or she has remained Clean and Sober. Serve up positive regard for any periods of sobriety. Take out a second piece of unlined paper and draw a timeline of 48 to 72 hours prior to the Client’s most recent usage and ask them what happened in that time period that may have begun the series of triggers to usage. (Please keep in mind that the most recent trigger which caused the purchase of drug or alcohol was only the last straw in a series of events).
Hand both Timelines to the Client and give them homework (yes!). Their assignments prior to the next scheduled therapy session are to create timelines of previous sobriety and a timeline if they use between sessions and what were the triggers and when did they begin.
5) Then talk with the Client about to their experiences with 12 Step Programs (if any). If there is a resistance to attending, recommend they attend at least one 12 Step Meeting between sessions and report back in the next session their experience so you can better understand what happened and why they feel the way they do. If there continues to be resistance to 12 Step Programs, ask if there are any sober friends they can call and talk with between sessions. (Of course both 12 Step and sober friends would be excellent at this stage of therapy).
6) Prior to the end of the session, dialog about your inbetween sessions contact process and how to schedule additional sessions if necessary. Should you choose to at the end of the session, serve up hope and support as a true partner in their longer-term recovery.
Although there are no hard and fast rules and one size of therapy does not fit all in early recovery, it is incumbent upon us to ensure we follow all the rules and regulations that the BBS expects we follow to the letter.
In my work with those in early recovery they tend to achieve long-term sobriety only when they are ready to and not one minute sooner. There are those who constantly slip and those few who achieve sobriety on the first time they choose to. Our role is to offer a handrail for them to hold onto as they work through the myriad of issues that have led to longer term usage.
There is hope. It is something I truly believe in.
Jeff Brosnan is a Licensed MFT who works with those in early recovery. Jeff has co-created and run Intensive Outpatient Programs both in Los Angeles and Palm Springs, worked in the Psychiatric Ward of Glendale Memorial Hospital with those who are in-patient status and facilitated Groups with Gay Men at The LA Gay and Lesbian Center. Jeff is in private practice in Los Angeles.