Wednesday, January 16, 2013

On the Question of Abstinence During Engagement: The Nature of Powerlessness in the Treatment and Coaching of those with Addiction Disorders

While I see strengths in both the arguments for and against strict abstinence during treatment for addiction, what I have witnessed over my nearly thirty years in the mental health field, and would prefer not to duplicate as a coach, is the exclusion of people who are actively displaying the symptoms of the disorder with which they need help.

In addition there is the often failed presumption that a substance abuse professional is able to, or should, be able to detect when someone is under the influence... either with their own assessment skills or by forcing medical procedures on people to determine their level of use before they can be treated for that use.

As an example of how much more powerful these addictions are than the skills of even the best professional, I want to relate an experience I recently had. A doctor had developed a long-term relationship with a patient who came to him regularly at various stages in her struggle with her addiction. He was convinced he could tell if she was inebriated or not. She claimed short-term sobriety.  Ultimately his treatment plan depended upon whether or not she was under the influence. I was called into the emergency room to do a mental health assessment, which I was required to do only after her blood alcohol level was under the allowable level, .08. The doctor told me he was convinced she had not been drinking, but due to her history was agreeable to proceeding with a blood alcohol level.  It turned out to be over .400. 

I think a rigid insistence that someone only come to sessions when they are free of substances may invite the kind of dishonest engagement in treatment and/or coaching that is a large part of the kind of negative counter-transference about addicts that turns what is more and more understood as a brain disease into a moral and/or character flaw. While we encourage addicts to admit to their powerlessness over their addiction, we demand that they exercise power over it before we will listen to them or help them.  Perhaps we should reconsider this rigid, even un-verifiable, standard and replace it with a more flexible one that only requires that the client or consumer of our services be made the responsible party and be able to tell us that he or she is “sober enough” to be able to engage.

It is important to me to remember that as much as we know it is self-destructive to do so, many addicts use in order TO function. By the time they are compelled to seek our assistance their brains and their bodies do not know how to function without the substance to which they are addicted.  While a certain level of mental sobriety may be necessary to constructively engage in order to make progress, it is unrealistic to demand absolute sobriety from people who may, in fact, NEVER truly be free of the addictive substances of choice at least during the stage of the disease prior to active engagement and change.

At a certain point this becomes more a topic about treatment for addictions than one about coaching. A coach probably would do best to consider his or her own proficiency and confidence level in dealing with an intractable, difficult-to-tame, illness of the brain and body chemistry.  Addiction can generally NOT be seen as, or treated as, the much simpler matter of a choice, or a moral failure to choose. Much current brain science indicates that in many addicts the urges, those powerful inner voices that make compelling but irrational excuses for to use again, are in fact nearly identical to what are called command hallucinations in people with Schizophrenic disorders. In a related fact, the statistics show that about 80% of those with addiction problems also have significant and serious co-occurring mental health issues.

I would encourage coaches to enter into this territory willingly; because I believe a coaching approach can be tremendously effective, but also cautiously and never alone. Make sure you have and make good use of a team of doctors, substance abuse professionals and resources, as well as those who are active in the recovery movement and groups like AA.