Chapter 11 - Dealing With Problems That Arise

Patients are repeatedly urged to arrive for all sessions promptly, to call if they are going to be late, and to call at least 24 hours in advance if they must cancel a session. If a patient fails to fulfill these obligations, the counselor will confront him or her about it in the session.

If a patient arrives late for a session, the consequence of that action is to have a shorter session, because the counselor will, and should, end the session on time. Repeated missed sessions without appropriate cancellations and rescheduling may eventually result in dismissal from the treatment, which should be made clear to the patient. In the original research program, administrative termination of treatment occurred only after 30 consecutive days of nonattendance, so patients were actually given many chances to participate before being terminated from treatment for nonattendance.

Patients are requested to arrive "clean" for all visits. If a patient arrives for a session obviously intoxicated, the counselor should remind the patient of his or her responsibility not to be high or intoxicated at sessions and reschedule the session. Clinicians should use personal judgment about how best to handle an individual event. For example, if a patient arrives for a session mildly under the influence but not intoxicated (blowing a low positive on a Breathalyzer®), the counselor must decide whether to continue with the session or reschedule. This situation is quite different from one in which the patient appears to have used just prior to the session, for example, in the parking lot.

Denial and questionable motivation are central themes in the beginning phase of addiction treatment. They are addressed in the initial sessions of counseling and are repeatedly addressed, as needed, throughout the course of treatment. The major strategy is to "chip away" at the patient's denial by pointing out the addictive behaviors and the actual consequences of addiction and by appropriately confronting the patient on the blindness of his or her denial.

Resistance is not a concept that is directly addressed as such in this addiction counseling model. In addiction counseling, much of resistant behavior falls within the concept of denial and is addressed in that way. For example, it would be denial if the patient refused to give up alcohol (when cocaine is the drug of choice) or avoid drug-using friends because of denial or minimization of the severity or consequences of the addiction. Another approach to dealing with resistance is to view it as the addict's willfulness which can be overcome by surrendering one's will to one's "higher power" in recovery - the meaning of the 12-step suggestion to "turn it over" or turn one's will over to a "higher power."

Regarding motivation, patients often express ambivalence at some point in treatment. Several strategies may be used, including encouraging patients to review the pros and cons of getting sober or explore fully the consequences of their addiction. Patients may also be asked to identify specifically the benefits of sobriety in their life. Essentially, these issues are reviewed continuously throughout the early period in treatment.

If the patient presents with an urgent, addiction-related problem like marital dissolution or financial problems as a result of the addiction, the counselor should try to address the problem. Emphasis should be placed on how the problem is related to the addictive behavior. Considerable effort should be taken to help the patient develop strategies for dealing with the problem in a manner consistent with recovery, including identifying how to obtain appropriate assistance from social services.

If the patient presents with a true crisis, such as having spent all of his or her money on a cocaine binge, and as a result, feeling suicidal, the counselor should address this issue immediately. The counselor may have to organize a team effort among the appropriate treatment staff to provide any medical or psychiatric services that the patient requires in order to remain safe.

If a relapse occurs, the counselor and patient should use the session immediately following the relapse to identify and process the events, thoughts, and feelings that precipitated the relapse. This step is called relapse analysis.

Relapse to drug use is a common occurrence that can be emotionally devastating to the patient. The counselor must communicate to the patient that a relapse to drug use does not mean that the entire treatment program has been a failure. Recovery is definitely not all or nothing. There is a residual savings. When patients relapse, the counselor will want to convey to them that they have lost their "clean time" but not the knowledge and experience gained during their recovery. The counselor should educate the patient about relapse and about the importance of taking corrective action rather than being overcome by feelings of depression or failure. Most episodes of drug use can be managed without seriously interrupting the treatment program. They can be used in a positive and educative way to strengthen the recovery process. In dealing with a relapse, the counselor should use the general principle that relapse is caused by failure to follow one's recovery program. Thus, the counselor should identify where the patient deviated from his or her recovery plan and help the patient to recommit to the recovery program.

Relapse can be viewed as having three levels of severity, which determine the appropriate therapeutic response. The counselor must understand the three types of relapse and the appropriate interventions to be used in each case. The counselor should communicate to the patient that any level of resumption of drug use is still a relapse, necessitating analysis of the process and recommitment to one's recovery program. In other words, a "slip" still is a relapse. The levels of severity are to assist the counselor in determining the appropriate action to be taken.

Slips

The least severe type of relapse is a "slip," a common occurrence that involves a very brief episode of drug use associated with no signs or symptoms of the dependence syndrome, as specified using the DSM-IV criteria (American Psychiatric Association 1994). Such an episode can serve to strengthen the patient's recovery if used to identify areas of weakness and point out solutions and alternative behaviors that can help prevent future drug use from occurring.

Several Days of Drug Use

The next most severe type of relapse is when the patient resumes drug use for several days, and the use is associated with some of the signs and symptoms of addiction. In such a case, the counselor probably would want to intensify treatment temporarily, which can be effective. We have found that intensified contact will usually reinstitute abstinence. The patient should be encouraged to review what happened and learn from the experience how to avoid a relapse in the future. The patient also should be encouraged to recommit to his or her recovery program.

Sustained Drug Use With Resumption of Addiction

The most serious form of relapse is a sustained period of drug use during which the patient fully relapses to addiction. Often a patient who relapses to this extent also will drop out of treatment, at least temporarily. In this case, if the patient returns to treatment, he or she may need to begin treatment with a detoxification phase, in either an inpatient or outpatient setting. The decision to detoxify a patient as an inpatient or an outpatient should be made conjointly by the treatment staff involved. Their decision should be based on the severity of the relapse, the particular drugs used, the availability of social support, and the presence of unstable medical or psychiatric conditions.

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