When the outside world looked at Julie Bates-Maves' client "James", they saw a 60-year-old "junkie" who had wasted 20 years of his life shooting heroin. But in James' heroin community, he was a respected man – a person of authority to be trusted.
James had established himself as a security professional during his two decades of addiction, says Bates-Maves, a member of the American Counseling Association. It may seem inappropriate to use the word “safety” when talking about heroin use, but safer injection practices can save lives. James was very happy to help his colleagues reduce the risk of HIV or hepatitis infection by teaching them never to share needles and demonstrating how to clean their own. He also taught others how to inject without missing the vein.
James' process of quitting heroin took about a year, but he managed to overcome physical addiction well, says Bates-Maves, a licensed professional counselor (LPC) whose master's degree in rehabilitation counseling with a focus on Alcohol and alcohol lies substance abuse counseling. The hard part was when James was alone and feeling lonely. He struggled with feelings of uselessness and knew where to find confirmation easily. Among other users, all James had to offer was to make his expertise available. There was always someone willing to take up his offer.
"He had found respect in virtually no other area of his life," says Bates-Maves. That meant that when James tried to give up heroin, he also had to leave behind that lonely piece of his world that made him feel worth it.
When Bates-Maves realized that heroin use was linked to James' self-esteem, she realized they needed to investigate what the behavior and related relationships were all about that made sense to him gifts.
"It was a lot to snap each other's brains and say, 'Let's try to break this apart," she recalls. They set out to uncover the real source of James's sense of consuming "Is it really tied to the syringe and the bleach and the cotton and the heroin?" She asked him. "Or is someone listening to you because they think you know something they don't know?"
Ultimately, James realized that he didn't really need the heroin. "I just need someone to look at me and say I'm smart and have something to offer," he told Bates-Maves. So they worked together to find another way for James to find purpose and feel like he had something to offer others.
At the beginning of his life James had pursued a welding career. He had given up this path a long time ago for various reasons. But now he was ready to take it up again.
With the help of Bates-Maves, James was re-enrolled in a technical welding program. When he went back to school, he learned skills not many people have, established new relationships, and experienced a sense of validation. He could say, "Hey, I'm 62, but I don't have to check out of the game and I don't have to be stagnant with everything I've done," Bates-Maves said. "I can add new things to my life, and by adding more to my life, I can expand other people's lives."
"Well," she adds, "it became a kind of altruism for him to want to give something to the world and then feel good about it."
James had been addicted to heroin for 20 years and realized that during that time he had injured others, especially his family, and had taken much away from them. "He had felt like a leech for a long time, and now it was finally time to give it back and pay it back," says Bates-Maves.
James was a turning point for Bates-Maves. His story changed the view of substance abuse counseling. James & # 39; tale wasn't just informative – it was existential. It made her realize that counselors need to have these kinds of discussions – about finding meaning, about the grief and loss that come with substance abuse – with all clients in recovery.
Bates-Maves and the other counselors interviewed for this article say that therapists focus treatment solely on removing the substance and everything related to it from the person's life – without considering the myriad of factors that lead to it Use, abuse, and illness all contribute to drive reuse – they actually hinder customer recovery.
The necessity of grief work in drug abuse therapy
"We over-simplify the image of addiction," says Bates-Maves. “We do this as a world in general, and we definitely do that sometimes in the consulting profession. … We see it as the erosion of a life – it's just someone moving backwards, it's just someone stuck. And we get stuck in this narrative. "
Counselors often focus on "getting rid of" clients, which is certainly not without value, but limited, says Bates-Maves, associate professor of clinical mental health at the University of Wisconsin-Stout. "I've worked with a lot of customers who … loved being stuck [in addiction]," she says. They loved the feeling of being someone else, the ability to lose sight of negative things, the ability to create an optional numbness.
Addiction sets the stage for a lot of destruction in people's lives, but it can also serve as a kind of desperate nourishment for users who see no other way to deal with life, says Bates-Maves. The stark truth is that substance abuse is life enriching, and counselors don't talk about that enough, she claims. Counseling is a profession that focuses on concepts such as identity and meaning of the person. However, counselors often neglect to examine how these concepts relate to addiction – what clients actually get from their substance abuse, what makes them attractive or useful to them, she says.
In portraying the role that grief and loss play in addiction, Bates-Maves has often heard from viewers that the clinics in which they work have advised them not to talk about the "good things" that substance use brings with it. She says the usual company line is: "You can't let them celebrate the highs or tell these so-called glory war stories. That encourages them to use their wish."
"We are so blinded by this fear that people will use it again," says Bates-Maves. "What if the glory days was the only time people felt powerful, or what if, when they are high, the only time they don't feel a strong [emotional or physical] pain?" What if only then do they feel safe enough to connect with another person? … These are central treatment problems, and they can arise from the non-positive "positive experiences" in addiction. There is a lot to let go of when trying to relax. There is a tremendous amount of losses, and [we’ve] has somehow largely missed that as a field. "
Bates-Maves is so aware of the need for counselors to have these conversations with clients as part of the recovery process that she wrote a book entitled Grief and Addiction: Considering Loss in the Recovery Process, which will be published in late September was
"Addiction … ravages your life," says Bates-Maves. "Nobody likes that." Even so, she continues, counselors need to encourage clients to reflect on the things they might lose if they choose to face their addiction.
"Even if they are good losses – things you want to get rid of – it's still a massive change you make," she tells customers. "You deserve to be sad and frustrated and sad … and relieved."
While the changes people go through in recovery need to take place, customers deserve to know that it is okay for them to miss the things that leave them behind. "You can miss it forever and still change," says Bates-Maves emphatically.
"If we try to get people to recover without even looking in the rearview mirror, we will miss the things that will later hunt them," she explains.
Bates-Maves believes that Kenneth Doka's model of disenfranchised grief perfectly explains the losses suffered by people struggling with addiction. During the recovery process, these clients usually have to give up coping methods and even unhealthy relationships. As such, these things are often viewed as "unworthy" to mourn about them.
Similarly, many patients in recovery have lost friends through stigmatized deaths such as overdose, suicide, hepatitis and AIDS. Other clients may have opted for an abortion or had a miscarriage due to their addiction. Once again, these individuals can feel like they shouldn't mourn these losses, says Bates-Maves. Family members in particular – and the courts – tend to convey the message: "You have dug your own hole."
But everyone has losses from predicaments that were primarily self-created, argues Bates-Maves. "I have this grief the whole time where I am the one who caused the problem, but I'm still very angry that I have it," she says.
Emotions that are denied usually just fester and show up in other ways, says Bates-Maves. “Just let people” – including those struggling with addiction – “be angry. Let them be sad. Just because we are the creators of our own misery doesn't mean we don't deserve to be unhappy about it, ”she says.
Consultants can assist clients when they realize that their current reality – whatever stage of addiction or recovery they are at – is incredibly difficult and involves myriad and often confusing emotions, says Bates-Maves. What counselors shouldn't do is tell clients that what they are feeling is wrong, or "cheer" them into a different emotional state, she continues.
People sometimes imagine that coping has overcome a difficulty so that it no longer has an emotional effect on them, says Bates-Maves. "I think it's really important that we all remember that coping isn't like that. Coping doesn't get over something. … It lives with something. It comes through while you're in it."
"My job as a consultant is not to relieve the pain because I can't," continues Bates-Maves. "It's not about forcing the transformation of pain. That's a hope, but sometimes it can take longer than my relationship with [the client]."
So what's the other side of grief? What is the goal of mourning work? Bates-Maves describes it as learning to go with your pain and carry it in a way that doesn't submerge you. "You want the pain to be manageable so you can live with it there," she says.
Bates-Maves recommends a variety of methods for helping clients, including those going through addiction and recovery, with their distress and pain. One method is containment – the idea of dividing the pain and creating a psychological space for it. She says this is especially useful for pain associated with situations that are unlikely to be resolved anytime soon. Some customers make actual physical boxes, write down their thoughts, feelings, or whatever is troubling them, and lock them up, but the container doesn't have to be literal, explains Bates-Maves.
The purpose of the exercise is not to hold the person's pain on forever, but to put it aside so that the person can move on with the other parts of their life. This recognizes the reality that the demands of life continue even when people are seriously injured. If a customer has time or inclination, they can open the container, sit with the pain, and feel what they are feeling. The ability to temporarily relieve pain allows clients to look after their children, drive to work, or just relax by watching TV or listening to music without constantly confronting intrusive thoughts, says Bates -Maves. Journaling is another way customers can create a space outside of their own heads for their emotions, she adds.
In contrast, radical acceptance, a method that is the exact opposite of locking one's thoughts away, can be very effective for some customers. "It's this idea that we can't always change things and we have to accept and acknowledge it and keep moving," says Bates-Maves. With radical acceptance, clients learn that their grief and pain are valid, but that they can feel those emotions and continue to move by their side.
Bates-Maves also had customers who had intense and disturbing dreams about their grief. She would teach them "directed dreaming". It took clients five to 15 minutes before going to bed to create detailed mental images of what they wanted to dream about. With practice, people can learn to direct their dreams, says Bates-Maves.
For customers who often feel overwhelmed, Bates-Maves recommends abdominal breathing. She explains that teaching people to breathe more efficiently can reduce panic breathing, which helps move the body from a state of distress to a state of relaxation, or at least closer to it.
Sometimes she helps clients transform their pain by learning to redefine their view of their losses. Certain customers realize that they will never think differently about parts of their past, but that they are okay with it. Some clients work with their pain by seeking connection with others. And some clients decide that they need to spend more time with themselves than with others in hopes of knowing who they are without addiction.
Attachment, trauma and addiction
Many people with addiction are prepared to seek solace in substances or processes because of trauma and a lack of healthy bonds, says ACA member Oliver J. Morgan, who has written numerous books on substance abuse and addiction. Caring relationships can help mitigate the effects of trauma in a child's life, while the absence of those connections is in itself traumatic. Feeling cared for helps build healthy neural connections like a fully functional stress response and the reward, reinforcement, and motivational systems that contribute to emotional coping skills, he explains.
If someone has difficulty dealing with stressors such as the ongoing pain of trauma, dysfunctional relationships, loneliness, or the everyday disappointments and frustrations of life, they may turn to addictive substances or behaviors, says Morgan, a licensed marriage and family therapist who has been clean and sober for over 30 years, but was once addicted to alcohol.
Over time, chronic use and abuse of substances or processes sensitize areas of the brain that are related to dopamine so that they can be easily triggered, he says. The brain then associates these areas with memory and environmental characteristics that generate desire themselves. In other words, addiction causes the brain to respond to cues that a client may not even know exist, says Morgan, creating what neurobiologists refer to as "impulses of desire."
"The brain organizes rewards around memories so that we remember to repeat [the action]," says Morgan, a master addiction advisor. "This is how we learn and fall in love." A certain song on the radio, certain places or people, or even certain scents can act as a trigger.
Therefore he regards every addiction counseling as relapse prevention. "Right from the start, you need to prepare people for the possibility, if not the likelihood of relapse," says Morgan, professor of counseling and human services at the University of Scranton.
He uses psychoeducation to explain the neurobiology that underlies addiction and relapse – not just clients, but their families too, if they are willing to listen. Morgan believes this is important to preventing a common scenario: a client falls behind and his family says, "He told me he was going to quit and he didn't." He lied to me. "
It's not that simple, says Morgan. He explains to families that when they say they are going to quit, their loved ones mean business, but they don't expect their brains to respond to these cues. So a relapse doesn't mean the customer isn't committed to recovery, says Morgan. Support from loved ones helps clients continue to devote themselves to the recovery process and continue to believe they can achieve it – even if they are temporarily derailed from relapse.
Morgan, a member of the International Association of Addictions and Offender Counselors, a division of ACA, believes relationships are the ultimate buffer against addiction. From the very beginning of the recovery process, he helps clients build new relationships with people who are clean and sober. You could develop these connections by finding sponsors or reaching out to strangers at Alcoholics Anonymous (AA), Narcotics Anonymous (NA), or other recovery group meetings and virtual gatherings.
Morgan also gives customers a laminated card with steps to take if they feel the urge to use it. This can act as a contingency plan of sorts or remind clients that they have tools in place to prevent relapse. The first step is to acknowledge their urge, but remember that it's just a feeling, not something to respond to.
Next, Morgan wants customers to reach someone they can trust and talk to. "The best way to deal with stress is to buffer with a relationship," he says. The person or persons customers contact can be sponsors, members of the Recovery Group, or Morgan herself. This gives customers a chance to share the burden by verbalizing their feelings and seeking advice. If none of this works, he prompts customers to call him (assuming he wasn't the person they originally reached).
Since the urge to use is triggered by external and internal cues that clients may not even be aware of, Morgan urges consultants to take these clients through their pasts. He asks customers to think about times when they used or wanted to use them. What happened in her life back then? What were your favorite songs? The more research into anything in their life, the more likely it is that potential relapse triggers can be identified.
"Sometimes," says Morgan, "you have to wait for them to come into the meeting and say," I really wanted to use "[to discover their triggers]so it's important that they have access [to you] when it happens [between sessions] so that you can walk through them. "Where were you? What happened? Who was with you?"
Once the client and counselor have identified triggering situations, they can work together to find better ways to deal with them. Morgan used humor in his own life as an alcoholic. "I make a joke of it and talk about it a lot," he says.
When Carol Sloan Goodall, a licensed clinical addiction specialist, was leading group work at a local recovery center, she often had clients form smaller circles to identify three external, three internal, and three sensory triggers. Group members also had to come up with three ways to deal with each trigger.
"I was often pleasantly surprised to see how many different realistic coping skills they created, and was thrilled that clients were impressed and motivated by these ideas," says Goodall, a licensed clinical mental health advisor in private practice in Charlotte, North Carolina.
Frequent external triggers concerned people, places and things. Internal triggers were usually emotions, but sometimes also food cravings, chronic pain or illness. Sensory triggers were just that – inputs from the five senses, such as smells, tastes, and sounds.
The coping skills of the customers varied. One customer described how he could avoid temptation by changing his route when he found his drug dealer lived on a specific street. Another customer felt their home was a trigger, so they rearranged the furniture and changed the color of the accessories to make them look new and different.
"A customer said he had a dryer sheet in his pocket and was sniffing at it when it was triggered by smells that reminded him of drug use," Goodall recalls. "Another customer said that the perfume cards you spray in department stores serve the same purpose."
Goodall also suggested that when customers encounter triggers, they could become distracted with sensations such as: B. crack a rubber band on your wrists or hold an ice cube.
Morgan believes that practicing mindfulness can help clients identify and even anticipate triggers. He teaches clients to sit down and find a place to focus – a point on the wall, a ray of sunshine, a candle. He then instructs them to simply "be" in that moment and watch what is happening around them in the here and now, cultivate awareness, and notice if the urge to use arises. He also finds this mindfulness practice helpful in dealing with fear and creating a sense of calm by just being in the moment, letting his thoughts and feelings float by, and then letting go.
The need to reduce the number of face-to-face meetings during the pandemic has made it somewhat easier for those recovering to get support. Groups like AA, NA, and other recovery organizations have quickly shifted their meetings to digital platforms. People can access virtual meetings via social media, email, or phone, or stay in touch with other group members. Consultant clinicians also had to familiarize themselves with virtual counseling. Morgan views this as positive, as he believes that it is easier for many people seeking substance abuse help not to have to appear in person to access resources. It's less uncomfortable for these customers, says Morgan, because they don't have to stand there all the way.
Go out of the prison
Julia Thielen, an LPC in South Dakota, works in an intensive care unit with a particularly challenging substance abuse population: clients living in a post-prison transition facility after 10 to 15 years of imprisonment
These clients not only work on recovery, but also on coping with trauma and trying to navigate through a world they do not recognize or understand, notes Thielen. They have records, have spent years without work, are often estranged from their families, have often lost friends to causes such as overdose, and struggle to develop a sense of identity. Life in general went on without her. The things that these customers once wanted – permanent jobs, families, their own house – now feel largely inaccessible to them, says Thielen.
The people around these customers often want to gloss over their circumstances and make them feel better, but what they really need, says Thielen, is someone who listens to them and helps them to set realistic goals. “Yes, you are over 30, so you won't have a house before that. But is it possible to do that at 40? “She asks her.
For clients who have spent a particularly long time in prison, it is a challenge to just get one job, says Thielen. They lack an employment history and are required to disclose that they spent time in prison. They need help finding employment just to restore a work history so that future employers in potentially more attractive jobs can later see them as responsible and hardworking, she explains.
Thielen and her colleagues not only teach these clients emotional self-regulatory skills such as deep breathing, but also teach them basic life skills. Many of these individuals spent their teens and young adulthoods in jail so they essentially skipped a developmental phase, she says.
Thielen's customers regularly talk about the challenges of finding healthy friends and activities. "One of the big things that they lack is any kind of support or stability in their life," she says. Bringing these clients to AA, NA, or some other recovery group is a way to build friendships with people who don't use them or who are also recovering.
Many of Thielen's customers don't know what healthy friendships look like, so she spends a lot of time helping them to recognize red flags from their previous relationships, for example behaviors that led them to or contributed to their addiction remained addicted. According to Thielen, these past-life friends have often called in sick when they were hungover, paid their fines for wrongdoing, or helped them find excuses for their probation officer.
Another piece of the puzzle is to help these customers articulate the values that potential friends should have. Often the easiest way to do this, says Thielen, is to ask them what values and beliefs they want to instill in their own children and, when forming new friendships, look for the same traits and qualities in others.
Most of Thielen's customers, however, are still closely connected to the people with whom they have previously worked. These are not "healthy" friendships, but many of these clients have no one in their life after they are released from prison. In many cases, their families and friends who were not co-users gave them up long ago. From the point of view of some customers, the people who were their co-users and maintained contact were “there” for them, and the customers want to return the favor. But spending time with these friends – who may not be interested in stopping their own substance use – is the most common route back to addiction, and often to reincorporation.
Some clients can have tough conversations and cut ties with people associated with their past drug abuse and prison time, says Thielen. Aber das ist fast unmöglich, bis sie neue Beziehungen aufgebaut haben. Deshalb ist es wichtig, sie in eine neue Gemeinschaft wie eine Selbsthilfegruppe, eine Suchterholungsgruppe oder eine Kirchengruppe zu bringen, sagt sie.
Eine weitere Herausforderung besteht darin, dass eine Übergangseinrichtung zwar Unterstützung und Schutz für diejenigen bietet, die kürzlich freigelassen wurden, die Umgebung jedoch der Lernverantwortung nicht sehr förderlich ist, sagt Thielen. Diese Klienten haben gelernt, bestimmte Regeln im Gefängnis zu befolgen, und jetzt lernen sie, andere Regeln in der Übergangseinrichtung zu befolgen, aber sie lernen nicht unbedingt, wie man ein Budget festlegt, wie man eine Mahlzeit kocht oder sogar wie Lebensmittel für sich selbst kaufen.
Thielen und ihre Kollegen versuchen, Kunden mit Fallmanagern und Trainern für Lebenskompetenzen zusammenzubringen, aber sie räumt ein, dass einige Personen gegen diese Art von Unterricht sehr resistent sind.
Prävention und Intervention
Berater haben die Möglichkeit einzugreifen – vor der Sucht, vor dem Gefängnis, bevor ein Leben aus der Bahn gerät. Morgan merkt an, dass der Fokus normalerweise auf jenen liegt, die körperlich von Substanzen abhängig sind, aber fast dreimal so viele Menschen problematische Benutzer sind. Und es sind diese Personen, die Berater am wahrscheinlichsten sehen, sagt er.
Morgan behauptet, dass Suchtprofis nicht unbedingt wissen, wie sie mit Personen umgehen sollen, die problematische Benutzer sind, aber die Suchtschwelle nicht erreicht haben. Erholungszentren sind für diese Personen nicht geeignet, weil sie nicht körperlich abhängig sind, sagt er.
Professionelle Berater können Kunden jedoch dabei helfen, ihren Problemgebrauch zu erkunden und zu erkennen, indem sie motivierenden Interviews und den Phasen des Wandels ausgesetzt sind, sagt Morgan. Oft sind diese Klienten im Büro des Beraters gelandet, weil sie Probleme bei der Arbeit, in der Schule, mit ihrer Familie oder anderen Beziehungen oder anderswo hatten. Sie können jeden Vorschlag einer „Problemnutzung“ rundweg ablehnen, aber Berater können vorschlagen, zu untersuchen, was im Leben dieser Klienten vor sich geht.
"Wenn sie dazu bereit sind, werden sie bereits in Betracht gezogen", sagt Morgan. Berater können diese Erkenntnis nehmen, dass etwas nicht ganz stimmt, und sagen: "Schauen wir uns an, wie Veränderungen aussehen", schlägt er vor. "Hören wir auf zu trinken, trinken wir weniger oder trinken wir weniger schädlich."
„Wir müssen auf Momente der Gelegenheit achten“, betont er. "Jemand wird für einen DUI angehalten – das ist ein Moment der Gelegenheit." Wenn jemand zu viel trinkt und zu Unfällen in der Wohnung neigt, ist jeder Besuch in der Notaufnahme eine Gelegenheit, fährt Morgan fort. Einige Krankenhäuser verwenden bereits Motivationsinterviews für kurze Eingriffe in die Notaufnahme, und die Erfolgsraten waren beeindruckend, sagt er.
Das Problem ist, dass zu lange die Botschaft lautete, dass Menschen mit Drogenproblemen Hilfe suchen werden, wenn sie bereit sind, sagt Morgan. Aber die meiste Zeit werden sie nicht alleine reinkommen, behauptet er.
"Wir müssen die Messlatte höher legen", schließt Morgan.
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Zusätzliche Ressourcen
To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:
International Association of Addiction and Offender Counselors (iaaocounselors.org)
IAAOC, a division of ACA, is an organization of professional substance abuse/addictions counselors, corrections counselors, students and counselor educators concerned with improving the lives of individuals exhibiting addictive or criminal behaviors.
Counseling Today (ct.counseling.org)
Books (imis.counseling.org/store)
A Concise Guide to Opioid Addiction for Counselors by Kelvin Alderson and Samuel T. Gladding
A Contemporary Approach to Substance Use Disorders and Addiction Counseling, second edition, by Ford Brooks and Bill McHenry
Addiction in the Family: What Every Counselor Needs to Know by Virginia A. Kelly
Treatment Strategies for Substance and Process Addictions by Robert L. Smith
Introduction to Crisis and Trauma Counseling edited by Thelma Duffey and Shane Haberstroh
Coping Skills for a Stressful World: A Workbook for Counselors and Clients by Michelle Muratori and Robert Haynes
Webinars and article for continuing professional development (aca.digitellinc.com/aca)
“Opiate Addiction and Chronic Pain: Overview of Counseling Approaches” with Geri Miller
“Opiate Addiction and Chronic Pain: Ethical Practices for Counseling Clients Who Live With Chronic Pain” with Geri Miller
“Opiate Addiction and Chronic Pain: Hope, Resilience and Self-Care Strategies for Counselors and Clients” with Geri Miller
“Substance Abuse/Disruptive Impulse Control/Conduct Disorder” with Shannon Karl
“Developmental Approaches in Treating Addiction” by Ford Brooks and Bill McHenry
“Complicated Grief: An Evolving Theoretical Landscape” by Laurie A. Burke, A. Elizabeth Crunk and E.H. Mike Robinson III
“Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Substance Misuse” with Amy E. Williams and Kristin Bruns
ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources)
Substance use disorders and addiction
Grief and loss
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Laurie Meyers is a senior writer for Counseling Today. Contact her at [email protected].
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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.
