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Complex patients deserve more compassionate care

July 17, 2017
by Les C. Lucas, LMFT
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It is exciting to see the progress the behavioral health field is making in services and service delivery. We have many ways of addressing substance use as well as other psychiatric disorders. We have grown and stumbled as we have continued what at times has been an arduous journey in figuring out what is or isn't effective in alleviating suffering and increasing functionality for complex clients/families. Substance use disorder services continue to evolve, starting long ago with self-help groups in response to multiple inpatient psychiatric hospital detoxifications and progressing to therapeutic communities to 28-day inpatient programs to short-term outpatient treatment to medication treatment to many variations of all of these. We can be proud of the progress we are making.

However, we are still experiencing growing pains. One area in which outpatient substance use disorder services has lagged behind the treatment of other psychiatric diagnoses involves minimum requirements for participating in clinical services.

Particularly, I have not seen or read much about efforts to engage clients and their families voluntarily seeking services, especially while they remain symptomatic (while they are still using/drinking). When this has been proposed, it has been argued against by many factions, including service providers, criminal justice/law enforcement professionals, child welfare agencies, families, faith communities, funding sources, etc.

Generally, on a day-to-day basis treatment staff are told to ignore these ideas and to continue to do “what worked for us.” Many are told, “I got into recovery this way, so it will work for these clients too.” In the face of this, and in many cases in spite of it, harm reduction and recovery-oriented philosophy and services have pushed the field toward efforts to engage clients/families who are living with the ongoing challenges of using, drinking and/or co-occurring disorders. This is an effective and much-needed approach to service delivery.

Still, the overall philosophy of substance use disorder services is that clients must be asymptomatic or not drinking/using. Unlike treatment of any other psychiatric disorder (schizophrenia, bipolar disorder, major depression, etc.), the outpatient substance use service delivery field maintains policies and practices that ask people to stop exhibiting the symptoms for which they want treatment before entering treatment. Then we will treat these symptoms that they have in partial remission. Also, the client may have to leave services when displaying symptoms (using/drinking), and/or the staff may label the person as “ not ready for recovery” when he/she does not succeed at being asymptomatic while receiving these services or after discharge, basically for the rest of his/her life.

Instead of decompensating (a common experience in ongoing recovery for all other psychiatric disorders) and then stabilizing again with the support of a voluntary and accepting service delivery staff, the client “relapses” and starts using/drinking again. We often tell the client that he/she will have to leave services for being too symptomatic of the illness, but that he/she can come back after becoming asymptomatic on one's own or at self-help groups. We then negatively judge the person upon return for having had symptoms and failing to stay in recovery.

My own transforming experience

Due to several factors, I decidedly turned away from this philosophy/approach more than 25 years ago. Since that time, I have seen hundreds of clients and their families become more functional and less symptomatic as they learn to live with substance use disorders (and more often, co-occurring disorders). I see them in my private practice as a family therapist and in publicly funded treatment services.

The vast majority of these clients come voluntarily, pay their bills like all other clients, cancel appropriately and reschedule new appointments. This population includes parents, adolescents, lawyers, police/correctional officers, physicians, truckers, pastors, brothers, sisters, teachers, business owners, wealthy/poor, educated/less educated, various cultural/ethnic groups, developers, construction company owners, nurses, occupational therapists, professors, and many others.

In 1991, I stopped using the old model. This occurred because of a simple yet profound interaction with a client.

I had terminated services with this client after I found out he was under the influence of alcohol during a session. I explained to him that I could not treat him while he was drinking because he was not able to participate rationally in psychotherapy if under the influence. I told him to stop drinking and then I would be happy to see him for therapy. He was crying when he left and said he would come back when he was sober. He never came back.

I remember driving home that night asking myself if I would have done that for any other psychiatric disorder. I realized quickly that the answer was no. I would never do that because symptoms are part of the psychiatric disorder presentation. I needed to see the symptoms to diagnose and treat someone with any other psychiatric challenge.

I would expect to see a depressed mood, congruent or incongruent affect, and other variables to make a diagnosis of major depressive disorder. I would want to know how long the symptoms had been occurring and if they had ever stopped, and if so, when and how. I would never ask anyone else to leave because they were symptomatic.