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Integrating substance dependence and pain management into counseling approaches

By Geri Miller November 5, 2020

In the United Sates, 2000-2010 was labeled the “decade of pain.” In 2011, the Institute of Medicine’s Committee on Advancing Pain Research, Care and Education stated that the prevalence of chronic pain in our country exceeded the prevalence of diabetes, heart disease and cancer combined.

Unfortunately, this prevalence of pain has continued, and because of that, counselors need to be aware that substance dependence and pain management may be an issue for their clients — even if it is not a “problem” as presented by clients themselves. Clients may be particularly vulnerable to substance dependence specific to opioids because they (or others in their lives) may view these drugs as the best treatment for pain (i.e., a “quick fix”).

There is a great deal to know about substance dependence and pain management. Because of this, counselors can easily become overwhelmed and hesitate to work with these issues. I am writing this article to help counselors see that they can readily integrate some basic substance dependence and pain management approaches into their current counseling practices and still be practicing within their area of competence.

Because of the prevalence of substance dependence and pain management in the United States, it would serve counselors well to always “wear the lenses” of both of these areas as they assess and treat their clients. However, it is probably most important for counselors who are working with clients specifically on either one of these two areas (substance dependence or pain management) to also intentionally explore the area not presented as a problem so that the potential relationship between the two is examined. For example, when counseling someone who struggles with chronic pain, a counselor would be well advised to also ask about their substance use. The same exploration needs to happen when a client struggles with substance dependence; a counselor should ask about any issues with pain and its management.

While this exploration is important, it is also imperative for counselors to be able to readily fuse these “lenses” into their existing clinical approaches. Five suggestions on the general process of incorporating these two perspectives follow.

First, counselors need to accept the reality that there is a lot to know about substance dependence and pain management and make sure that they work within their area of competence. One method for exploring and addressing these areas with their clients (while still practicing in their area of competence) is to use the “HOW” approach. This acronym encourages counselors to be honest, open and willing to discuss substance dependence and pain management issues with their clients. For example, a counselor can be honest about not knowing much about the client’s experience of pain, be open to being educated about the client’s perspective and be willing to discuss the pain experience with the client.

Second, counselors can anchor their approach in the discussion with respect for and genuineness toward the client. This client-centered approach inherently invites the client’s story of their pain (including the ways they try to handle the pain, such as opiates).

Third, counselors can assess and treat the pain using their typical counseling approaches and continue reassessment throughout the treatment process. Counselors should operate as gatherers of information about the pain and, as appropriate, consult with others (e.g., mentors, supervisors, colleagues, medical professionals) concerning appropriate ways to address the pain.

Fourth, counselors need to be aware of countertransference related to their own and their loved ones’ experiences with pain management and substance dependence. An awareness of their countertransference can enhance counselors’ effectiveness in addressing these overlapping areas.

Finally, counselors need to work within the realistic resource limitations that both they and their clients experience. For example, both counselors and their clients have limitations on the amount of time, energy and money they can invest in learning about and addressing the issues of substance dependence and pain management. Maintaining such a realistic perspective can cultivate more humane and practical counseling interventions that will result in less frustration for both the counselor and client.

An overview of chronic pain

In 2011, as stated previously, the Institute of Medicine’s Committee on Advancing Pain Research, Care and Education reported that chronic pain exceeded the combination of diabetes, heart disease and cancer in terms of prevalence in the United States. These historical statistics, in which the current issues of substance abuse and pain management are anchored, underscore the likelihood that many of our counseling clients are experiencing chronic pain but have not mentioned it or its impact on their lives in session. This prevalence should serve as an invitation for counselors to discuss pain and pain management with their clients.

In 2019, Beth Darnall, a pain scientist and director of the Stanford Pain Relief Innovations Lab, summarized the following information on chronic pain in her book Psychological Treatment for Patients With Chronic Pain. By definition, chronic pain is pain that lasts longer than three months or that extends beyond the expected time it should take to heal. Breakthrough pain is an acute version of chronic pain and centers on days or times when the pain is worse.

Although Darnall called chronic pain a “harm alarm” that tells the person to escape the pain to survive, she said the “riddle of chronic pain” is that it is impossible to escape. This knowledge needs to be fused into the perspective of how the pain experience is affecting our counseling clients in a biopsychosocial manner. This biopsychosocial exploration of the relationship between the overlapping areas of substance abuse and pain management can be facilitated by the core suggestions presented in the following section.

Core suggestions

I offer seven core suggestions that counselors can use as a guide in addressing substance dependence and pain management from a biopsychosocial perspective.

1) Work out of a systems perspective. From this perspective, the counselor looks at the systemic interactions that result separately for addiction and pain, as well as their overlap systemically. This means that the counselor is aware of the internal and external contributing factors for both addiction and pain and that the client may have developed an addiction in response to their pain or vice versa. The addiction may have resulted from prescribed medication following surgery, or the pain may have resulted from an accident that occurred while the client was under the influence of alcohol or drugs.

2) Watch for prescribed and nonprescribed substance use. This suggestion means that the counselor obtains information from the client about any prescribed medication of substances (such as medication-assisted treatment) in response to their pain or substance dependence as well as the client’s nonprescribed usage of opiates and marijuana for pain. Such an inclusive gathering of information provides the counselor with a broader view of the client’s treatment responses to managing the pain.

3) Practice “compassionate accountability.” This phrase means that the counselor has compassion for the client and simultaneously holds the client accountable for their behavior. For example, I can have compassion that my client has an addiction resulting from their use of opiates in response to chronic pain that prevents the client from performing activities of daily living. However, I also need to hold the client accountable for their behavior, such as stealing prescription opiates from a friend’s medicine cabinet.

4) Use firm, direct, honest communication. This is complementary to exercising compassionate accountability because this form of communication avoids enabling behaviors related to both pain management and addiction. No matter what, clients are responsible for the choices they make, and counselors need to be clear with clients about what they see.

5) Consider a harm-reduction perspective. This perspective means that the counselor walks the fine line of not enabling the client’s substance use while at the same time not requiring the client to suddenly commit themselves to abstinence. Instead, the counselor works within the reality of the client’s willingness and ability to change without encouraging the client to remain at the same level of change.

6) Complete assessment and treatment plans for both addiction and pain. This involves the counselor examining both areas in a broad way that includes the client’s fear of the pain returning and their psychological withdrawal from pain medication.

7) Watch for behavioral indicators of pain during the session. A significant amount of information can be gathered when the client is actively experiencing pain. The client’s pain experience can be processed in the moment, and the resulting information can assist both the assessment and treatment processes.

Assessment

Counselors can use a simple anchoring assessment prompt to elicit each client’s story: “Tell me the story of your pain.”

That open-ended prompt has the power to draw out narratives that clients have perhaps not spoken about previously. These clients may be accustomed to closed questions or scaling questions regarding their pain, but they may never have had anyone ask about and then carefully listen to the actual story of their pain.

This motivational interviewing approach can readily draw out information about the impact of community, culture, family and multicultural factors on the individual’s self-report. For example, the client may talk about how pain is simply not discussed in their family and culture. As a result, they have learned not to reach out for support to address their pain. The counselor could then help the client develop skills to reach out to others who will be supportive of them as they live with their pain, or the counselor might refer the client to a group that discusses pain management approaches.

Another assessment approach is to have clients keep diaries or logs pertaining to their pain, sleep and nutrition. These logs can assist in obtaining information about pain patterns and contributing factors to pain. Such record-keeping also needs to focus on what the client is doing “right” as well as what they are doing “wrong,” in addition to times when the areas of pain, sleep and nutrition are going well for the client. The collection of this information is solution-focused and strength-based. It can become the cornerstone on which healing treatment is built.

The assessment of pain also needs to be considered within the context of addiction. So, although the client has pain, this does not mean that it is necessary for them to use substances to cope with that pain. Neither does the existence of pain prevent the client from being confronted about their addiction as a “stand-alone” diagnosis.

Thus, the message is twofold:

1) The client can learn to live with pain without the use of substances.

2) The client may need to be confronted solely on their use of substances.

Treatment

Treatment for pain can involve various therapy modalities such as individual, group or family counseling. The counselor and client can choose the modality that seems to best fit the needs of the client, in combination with the resources available related to client income, agency resources and community resources.

Specific therapy approaches can include motivational interviewing, cognitive behavior therapy, acceptance and commitment therapy, and grief counseling (because when dealing with chronic pain, clients frequently have issues of loss). It is within these forms of therapy where clinicians can legitimately practice counseling in their areas of competence by simply anchoring themselves in their treatment approach (e.g., therapy modalities, specific therapy approaches) and adding the lenses of “pain” and “substance abuse” by asking about information in the assessment process that broadly addresses these areas. Such broad assessment can assist the counselor in knowing whether the treatment of pain and substance use can be readily integrated into treatment or whether a more specific assessment and focused treatment of these areas are required.

Treatments that change the client’s relationship with the pain by focusing on the present (e.g., mindfulness, yoga, biofeedback, acupuncture) are also potential resources. In such cases, clients may remain aware of the pain but work with the knowledge that the intensity of their pain ebbs and flows and learn how to live with that process. They may also find techniques to reduce their pain.

Another treatment approach, described by Kirsten Weir in 2017 in Monitor on Psychology, encourages the client to practice self-care of the body through diet, exercise and sleep. It uses the metaphor of a stool with three legs. I developed the diagram above for the fifth edition of my book Learning the Language of Addiction Counseling (currently in press) to illustrate this metaphor.

The three-pronged stool is precariously balanced, which illustrates that self-care is not a static entity but rather one that needs to fluctuate depending on the client and the context. Each leg of the stool (diet, exercise, sleep) is needed to keep the overall stool (self-care) in balance. In other words, each leg has an impact on the others. For example, the experience of pain may negatively affect a client’s sleep, which then inhibits them from exercising and tempts them to eat unhealthy comfort foods. In contrast, a client who gets enough sleep may experience diminished pain, thus encouraging them to exercise and practice healthy eating. Counselors need to remind clients, however, that “pretty good” self-care is good enough; one does not have to practice “perfect” self-care to reap the benefits.

A final treatment approach involves counselors viewing themselves as part of a health management team. Such a team can consist of different health care professionals in which each professional has an important perspective on the unique aspects of the individual client’s pain and pain management. The unique components of the client’s pain determine the composition of such a team and the treatment system in which the team exists (e.g., hospital setting, private practice). Whether the team is formally or informally established by the counselor or by the system in which the counselor works, the counselor provides a critical mental health perspective that is needed for a holistic treatment approach.

As part of such a team, counselors familiarize themselves with any prescribed medications that the client is taking for chronic, active disorders. Counselors then play a role in the planned and gradual reduction of medications being taken. Counselors do not need to be experts in pain management or medications to be part of such a team or to be assigned to a formal team. The team approach can be extremely effective in serving the welfare of clients.

The counseling perspective offers important contributions to such teams, including a heightened sensitivity for clients’ pain stories and a commitment to advocating for clients. Such a perspective can result in an effective and humane approach to pain management and the use of prescription drugs. Additionally, this perspective can prevent clients from feeling like they are being dehumanized on a “medical assembly line” during the treatment process.

Conclusions

Clinicians can work effectively with clients by integrating pain management and substance use approaches into their already-existing counseling approaches. Awareness of the prevalence of chronic pain and its potential interaction with substance use can assist counselors during the assessment and treatment process.

Chronic pain and substance use frequently overlap, but they are areas that can easily be missed in terms of their impact on clients’ presenting problems. Simply by integrating the lenses of pain management and substance use into their counseling — asking questions and intervening as necessary — clinicians can offer a more holistic approach to their clients.

The development of these lenses can be enhanced through continuing education, ongoing training and staying informed on current research. There are some excellent resources (see below) that counselors can add to their clinical toolboxes. Counselors who commit to more deeply examining the areas of pain management and substance use can improve their overall treatment effectiveness and, thus, act in the best interests of their clients.

Recommended resources

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Learn more: ACA has produced a series of webinars with Miller on this topic. See more at ACA’s Professional Development Center: https://aca.digitellinc.com/aca/speakers/view/22581

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Geri Miller is a licensed professional counselor, licensed clinical addiction specialist, certified clinical supervisor, master addiction counselor, licensed psychologist, diplomate in counseling psychology and a professor in the Department of Human Development and Psychological Counseling at Appalachian State University. She has worked in the counseling profession since 1976 and in the addictions field since 1979. She has published and presented research on counseling, and the fifth edition of her book Learning the Language of Addiction Counseling is currently in press. Contact her at millerga@appstate.edu.

 

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

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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.

Addiction: Paving the way to recovery

By Laurie Meyers October 26, 2020

When the outside world looked at Julie Bates-Maves’ client “James,” it saw a 60-something “junkie” who had wasted 20 years of his life shooting up heroin. But in James’ community of people who used heroin, he was a respected man — an authority figure who could be trusted.

Throughout his two-decade addiction, James had established himself as a safety expert, recounts Bates-Maves, a member of the American Counseling Association. It might seem incongruous to use the word “safety” when speaking about heroin use, but safer injection practices can save lives. James derived great satisfaction from helping his peers reduce their risk of contracting HIV or hepatitis 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 giving up heroin took about a year, but he did well with overcoming the physical addiction, says Bates-Maves, a licensed professional counselor (LPC) whose master’s degree is in rehabilitation counseling with a concentration in alcohol and substance abuse counseling. The hard part was when James was alone and feeling lonely. He struggled with feelings of uselessness, and he knew where he could readily find validation. Among other users, all James had to do was offer to lend his expertise. There was always someone willing to take him up on his offer.

“He had not found respect in virtually any other area of his life,” Bates-Maves says. That meant that in trying to give up heroin, James would also have to leave behind the solitary piece of his world that made him feel worthwhile.

Once Bates-Maves understood that using heroin was tied to James’ sense of self, she realized they needed to examine what it was about the behavior and the attached relationships that provided him with a sense of meaning.

“It was a lot of picking each other’s brains and saying, ‘Let’s try to dissect this,’” she recalls. They set about trying to uncover the actual source of the sense of meaning that James derived from using heroin. “Is it truly tied to the syringe and the bleach and the cotton and the heroin?” she asked him. “Or is it that somebody is listening to you because they think you know something that they don’t?”

Ultimately, James realized that he didn’t actually need the heroin. “I just need someone to look at me and think I’m smart and that I have something to offer,” he told Bates-Maves. So, they worked together to identify another way for James to find a sense of meaning and feel as if he had something to offer others.

Earlier in his life, James had pursued a welding career. For various reasons, he had abandoned that path long ago. But now, he was ready to pick it up again.

With Bates-Maves’ help, James got re-enrolled in a tech program for welding. By going back to school, he acquired a skill set that not many people possess, built new relationships and experienced a sense of validation. He was able to say, “Hey, I’m 62, but I don’t have to check out of the game, and I don’t have to stay stagnant in everything I’ve done,” Bates-Maves explains. “I can add new things to my life, and by adding more to my life, I can add to other people’s lives.”

“So,” she adds, “it became sort of a sense of altruism for him of wanting to give to the world and then to feel good about doing that.”

James had been addicted to heroin for 20 years and recognized that over that time, he had hurt and taken a lot from others, particularly his family. “He had kind of felt like a leech for a long time, and now it was finally time to be able to give that back and repay,” Bates-Maves says.

James was a watershed client for Bates-Maves. His story was the one that changed how she viewed substance abuse counseling. James’ narrative hadn’t been just informational — it had been existential. It made her realize that counselors need to have those types of discussions — about the search for meaning, about the grief and loss that come with substance abuse — with all clients in recovery.

Bates-Maves and the other counseling professionals interviewed for this article say that when therapists center treatment solely on elimination of the substance and everything associated with it from the person’s life — without considering the myriad factors that contribute to use, abuse and the drive to reuse — they are actually hampering clients’ recovery.

The need for grief work in substance abuse therapy

“We oversimplify the picture of addiction,” Bates-Maves says. “We do that as a world broadly, and we definitely do that in the counseling profession sometimes. …We think of it as the erosion of a life — it’s only somebody moving backward, it’s only someone being stuck. And we get stuck in that narrative.”

Counselors often focus on getting clients “unstuck,” which is certainly not without worth, but it is limited, says Bates-Maves, an associate professor of clinical mental health at the University of Wisconsin-Stout. “I’ve worked with many clients 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 sustenance for users who see no other way to cope with life, Bates-Maves says. The bald truth is that substance abuse also adds things to life, and that’s something counselors don’t talk about enough, she asserts. Counseling is a profession that focuses on concepts such as identity and a person’s sense of meaning, yet counselors often neglect to explore how these concepts tie in to addiction — what clients are actually getting from their substance abuse, what makes it attractive or useful to them, she says.

When presenting on the role that grief and loss play in addiction, Bates-Maves has frequently heard from audience members that the clinics in which they work have told them not to talk about the “good stuff” that substance use brings. She says the usual company line is, “You can’t have them celebrate the high or tell those so-called glory war stories. That’s encouraging their desire to use.”

“We’re so blinded by this fear of people going back to use,” Bates-Maves says. “What if the glory days were the only time people felt powerful, or what if when they’re high, it’s the only time they don’t feel intense [emotional or physical] pain? What if it’s the only time they feel confident enough to engage with another human? … Those are central treatment issues, and they can come out of the quote-unquote ‘positive experiences’ in addiction. There’s a lot to let go of when you’re trying to get to recovery. There’s a tremendous amount of loss, and [we’ve] somehow largely missed that as a field.”

Bates-Maves feels so strongly about the necessity of counselors having these conversations with clients as part of the recovery process that she wrote a book, Grief and Addiction: Considering Loss in the Recovery Process, which was released at the end of September.

“Addiction … ravages your life,” Bates-Maves says. “Nobody likes that.” Even so, she continues, counselors need to encourage clients to think about the things they risk losing when they determine to confront their addiction.

“Even if they’re good losses — things you want to go away — it’s still a massive change that you’re undertaking,” she tells clients. “You deserve to feel sad and frustrated and sorrowful … and relieved.”

Even though the changes people go through in recovery need to happen, clients deserve to know that it’s OK for them to miss the things they leave behind. “You can miss it forever and still change,” Bates-Maves says emphatically.

“When we start to try and shove people forward to recovery without looking at the rearview mirror at all, we’re going to miss the things that will chase them down later,” she explains.

Bates-Maves believes Kenneth Doka’s model of disenfranchised grief perfectly explicates the losses sustained by people struggling with addiction. In the recovery process, these clients typically must abandon coping methods and even relationships that are unhealthy. As such, these things are often deemed “unworthy” of grieving over.

Similarly, many clients in recovery have lost friends to stigmatized deaths such as overdose, suicide, hepatitis and AIDS. Other clients may have chosen abortion or had a miscarriage because of their addiction. Once again, these individuals can be made to feel that they aren’t allowed to grieve those losses, Bates-Maves says. In particular, family members — and the courts — tend to convey the message, “You dug your own hole.”

But everyone has losses from predicaments that are primarily self-created, Bates-Maves argues. “I have this grief all the time where I’m the one who caused the problem, but I’m still really mad that I have it,” she says.

Emotions that are denied usually just fester and show up in other ways, Bates-Maves says. “Just let people” — including those struggling with addiction — “be angry. Let them be sad. Just because we’re the creators of our own misery does not mean we don’t deserve to be miserable about it,” she says.

Counselors can offer clients support as they learn to acknowledge that their current reality — whatever stage of addiction or recovery they’re in — is incredibly tricky and comes with myriad, and often confusing, emotions, Bates-Maves says. What counselors shouldn’t do is tell clients that what they’re feeling is wrong or try to “cheerlead” them into a different emotional state, she continues.

People sometimes picture coping as having overcome a difficulty so that it no longer has any emotional effect on them, Bates-Maves says. “I think it’s really important for all of us to remember that’s not what coping is. Coping isn’t getting over something. … It’s living with something. It’s getting through it as you’re in it.”

“My job as a counselor is not to make the pain go away, because I can’t,” Bates-Maves continues. “It’s not to force the transformation of pain. That’s a hope, but sometimes that can take longer than my relationship with [the client].”

So, what is the other side of grief? What is the goal of grief work? Bates-Maves describes it as learning to walk with and carry your pain in a way that doesn’t sink you. “You want the pain to be manageable so that you can live life with it there,” she says.

Bates-Maves recommends a variety of methods to help clients, including those walking through addiction and recovery, with their grief and pain. One method is containment — the idea of compartmentalizing the pain and building psychological space for it. She says this is particularly useful for pain attached to situations that are unlikely to be resolved anytime soon. Some clients make actual physical boxes, write down their thoughts, feelings or whatever it is that is causing them distress, and lock it up, but the container need not be literal, Bates-Maves explains.

The intent of the exercise is not to lock the person’s pain up forever, but rather to put it aside so that the person can carry on with the other parts of their life. This acknowledges the reality that even when people are hurting badly, the demands of living go on. When a client has the time or desire, they can open the container, sit with the pain and feel whatever they feel. Being able to set aside the pain temporarily allows clients to care for their children, drive to work or even just relax by watching TV or listening to music without being confronted by constant intrusive thoughts, Bates-Maves says. Journaling is another way that clients can create a space outside of their own heads for their emotions, she adds.

In contrast, radical acceptance, a method that is the polar opposite of locking one’s thoughts away, can be very effective for some clients. “It’s this idea that we cannot always change things and we need to accept and acknowledge it and keep moving,” Bates-Maves says. With radical acceptance, clients learn that their grief and pain are valid but that they can feel those emotions and still keep moving alongside them.

Bates-Maves has also had clients who experienced intense and disturbing dreams about their grief. She would teach them “directed dreaming.” Clients would take five to 15 minutes before going to bed to create detailed mental pictures in their minds of what they wanted to dream about. With practice, people can learn to direct their dreams, Bates-Maves says.

For clients who frequently feel overwhelmed, Bates-Maves recommends belly breathing. She explains that teaching people to breathe more efficiently can reduce panicked breathing, which helps take the body from a state of distress to one of relaxation, or at least closer to it.

She sometimes helps clients transform their pain by learning to reframe how they view their losses. Certain clients realize that they will never feel differently about parts of their past but that they are OK with that. Some clients work through their pain by seeking connection with others. And some clients decide that they need to spend more time with themselves rather than with others, hoping to learn who they are without addiction.

Attachment, trauma and addiction

Many people with addiction have been primed to seek solace in substances or processes because of a history of trauma and a lack of healthy attachments, says ACA member Oliver J. Morgan, who has written numerous books on substance abuse and addiction. Caring relationships can help mitigate the effect of trauma in a child’s life, whereas a lack of those connections is traumatic in itself. Feeling cared for helps build healthy neural connections such as a fully functional stress response and the reward, reinforcement and motivation systems that contribute to emotional coping skills, he explains.

When someone finds it difficult to cope with stressors such as the lasting pain of trauma, dysfunctional relationships, loneliness or the everyday disappointments and frustration 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 once was addicted to alcohol.

Over time, chronic use and abuse of substances or processes oversensitize areas of the brain related to dopamine so that they are easily triggered, he says. The brain then connects those areas to memory and environmental cues that themselves create desire. In other words, addiction causes the brain to react to cues that a client may not even know exist, Morgan says, creating what neurobiologists call “pulses of craving.”

“The brain organizes reward around memories so that we remember to repeat [the action],” says Morgan, a master addiction counselor. “It’s how we learn and how we fall in love.” A particular song on the radio, specific places or people, or even certain scents can serve as triggers.

That’s why he views all addiction counseling as relapse prevention. “From the beginning, you need to prepare people for the possibility, if not probability, of relapse,” says Morgan, a professor of counseling and human services at the University of Scranton.

He uses psychoeducation to explain the neurobiology underlying addiction and relapse — not just to clients, but to their families if they are willing to listen. Morgan believes this is essential to preventing a common scenario: A client relapses and their family says, “He told me he was going to stop and he didn’t. He lied to me.”

It’s not quite that simple, Morgan says. He explains to families that their loved ones mean it when they say they’re going to stop using, but they’re not anticipating that their brains are going to react to these cues. So, a relapse doesn’t mean that the client isn’t committed to recovery, Morgan says. The support of loved ones helps clients remain dedicated to the recovery process and keep believing that they can achieve it — even if they are momentarily derailed by a relapse.

Morgan, a member of the International Association of Addictions and Offender Counselors, a division of ACA, believes that relationships are the ultimate buffer against addiction. From the start of the recovery process, he helps clients begin forging new relationships with people who are clean and sober. They might 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 clients a laminated card with steps to take if they feel the urge to use. This can function as a kind of crisis plan or serve as a reminder to clients that they have tools to help prevent relapse. The first step is to acknowledge their urge but to remind themselves that it is just a feeling, not something that they have to act on.

Next, Morgan wants clients to reach out to someone whom they trust and can talk to. “The best way to deal with stress is to buffer with a relationship,” he says. The person or people clients reach out to could be a sponsor, recovery group members or Morgan himself. This gives clients a way to share the burden by verbalizing their feelings and getting some advice. If none of this works, he tells clients to call him (assuming he wasn’t the person they reached out to initially).

Because the urge to use is triggered by external and internal cues that clients may not even be aware of, Morgan urges counselors to walk these clients through their past. He asks clients to think about times when they were using or wanted to use. What was happening in their lives at the time? What were their favorite songs? The broader the exploration of everything in their lives, the more likely it is that potential relapse triggers can be identified.

“Sometimes,” Morgan says, “you have to wait for them to come into session and say, ‘I really wanted to use’ [to discover their triggers]. That’s why it’s important to let them have access [to you] when it happens [between sessions] so that you can walk them through it. ‘Where were you? What happened? Who was with you?’”

Once the client and counselor have identified triggering situations, they can work together to come up with better ways to handle them. In his own life as someone who was addicted to alcohol, Morgan uses humor. “I make a joke out of it and talk about it widely,” he says.

When Carol Sloan Goodall, a licensed clinical addictions specialist, led group work at a local recovery center, she frequently 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 cope with each trigger.

“I was often pleasantly surprised to see how many different realistic coping skills they created and excited to see the clients impressed and motivated by these ideas,” says Goodall, a licensed clinical mental health counselor in private practice in Charlotte, North Carolina.

Common external triggers involved people, places and things. Internal triggers usually involved emotions but sometimes also included cravings, chronic pain or illness. Sensory triggers were just that — input from the five senses, such as smells, tastes and sounds.

The coping skills that clients came up with were varied. One client described avoiding temptation by changing their route upon realizing that their drug dealer lived on a particular street. Another client felt like their home was a trigger, so they rearranged the furniture and changed the color of the accessories to make it appear new and different.

“One client said he carried a dryer sheet in his pocket and sniffed it when triggered by scents reminding him of drug use,” Goodall recalls. “Another client stated that the perfume cards you spray in department stores served the same purpose.”

Goodall also suggested that when confronted by triggers, clients could distract themselves with sensations such as snapping a rubber band on their wrists or holding an ice cube.

Morgan is a believer that practicing mindfulness can help clients identify and even anticipate triggers. He teaches clients to sit down and find a place on which to focus — a spot on the wall, a beam of sunlight, a candle. Then he instructs them to just “be” in that moment and observe what is happening around them in the here and now, to cultivate awareness and to notice if the urge to use is creeping up. He also finds this mindfulness practice helpful for coping with anxiety and creating a sense of calm by just being in the moment, letting one’s thoughts and emotions float by, and then letting them go.

The necessity of reducing in-person meetings during the pandemic has in some ways made it easier for those in recovery to get support. Groups such as AA, NA and other recovery organizations swiftly moved their meetings to digital platforms. People can access virtual meetings or keep in touch with other group members through social media, email or phone. Counselor clinicians have also had to become more comfortable with virtual counseling. Morgan sees this as a positive because he thinks not having to show up in person to access resources is easier for many people who are seeking help with substance abuse. It’s less uncomfortable for these clients, Morgan says, because they don’t quite have to put themselves out there completely.

Going from prison to the outside world

Julia Thielen, an LPC located in South Dakota, works at an intensive outpatient facility with a particularly challenging substance abuse population: clients living in a post-prison transitional facility after being incarcerated for as long as 10 to 15 years.

These clients are not only working toward recovery, but also coping with trauma and trying to navigate a world that they don’t recognize or understand, Thielen notes. They have records, have spent years without employment, are often estranged from their families, have often lost friends to causes such as overdose, and struggle to form a sense of identity. Life has generally moved on without them. The things these clients may have once wanted — steady jobs, families, a house of their own — now feel largely out of reach to them, Thielen says.

Those around these clients often want to sugarcoat their circumstances and make them feel better, but what they really need, Thielen says, is someone to hear them out and help them set realistic goals. “Yes, you are past 30, so having a house before then is not going to happen. But is it possible to achieve that by 40?” she asks them.

For clients who have spent a particularly long time in prison, just getting a job is challenging, Thielen says. They lack a history of employment and have to disclose that they spent time in prison. They need help finding any form of employment just to reestablish a work history so that further down the line, future employers at potentially more attractive jobs might be able to see them as responsible and hard-working, she explains.

In addition to teaching these clients emotional self-regulation skills such as deep breathing, Thielen and her colleagues instruct them in basic life skills. Many of these individuals spent their adolescence and young adulthood in prison, so in essence, they have skipped a developmental stage, she says.

Thielen’s clients regularly talk about the challenges of finding healthy friends and activities. “One of the big things they are lacking is any kind of support or stability in their lives,” she says. Getting these clients involved with AA, NA or another recovery group is one way to help them establish friendships with people who don’t use or who are also in recovery.

Many of Thielen’s clients don’t know what healthy friendships look like, so she spends a significant amount of time helping them identify red flags from their past relationships, such as behaviors that led them toward addiction or contributed to them staying addicted. Often, Thielen says, these friends from clients’ former lives would call in sick for the client when they were hungover, pay their fines for misbehavior or help them come up with excuses for their probation officer.

Another piece of the puzzle is to help these clients articulate what values they would like potential friends to possess. Often, the easiest way to do this, Thielen says, is to ask them what values and beliefs they would like to instill in their own children and to look for those same characteristics and qualities in others when forming new friendships.

But most of Thielen’s clients still have strong ties to the people they previously used with. These aren’t “healthy” friendships, but many of these clients have no one else in their lives upon being released from prison. In many cases, their families and any friends they had who weren’t fellow users have given up on them long ago. From the perspective of some clients, the people who were their fellow users and have maintained contact have “been there” for them, and the clients want to reciprocate. But spending time with these friends — who may not be interested in stopping their own substance use — is the most common road back to addiction and, often, reincarceration.

Some clients can have the hard conversations and cut ties with the people who are linked to their past substance abuse and prison time, Thielen says. But that’s almost an impossible ask until they have formed new relationships. That is why getting them into some type of new community such as a self-help group, addiction recovery group or church group is critical, she says.

Another challenge is that although a transitional facility can offer support and shelter to those who have recently been released, the environment isn’t very conducive to learning responsibility, Thielen says. These clients learned to follow a particular set of rules in prison, and now they learn to follow another set of rules in the transitional facility, but they aren’t necessarily learning how to set a budget, how to cook a meal or even how to buy groceries for themselves.

Thielen and her colleagues attempt to set clients up with case managers and life skills coaches, but she acknowledges that some individuals are very resistant to this kind of instruction.

Prevention and intervention

Counselors do have opportunities to intervene — before addiction, before prison, before a life goes off the rails. Morgan notes that while the focus is typically on those who are physically addicted to substances, almost three times as many people are problem users. And it is these individuals whom counselors are most likely to see, he says.

Morgan asserts that addiction professionals don’t necessarily know how to deal with those individuals who are problematic users but have not reached the threshold for addiction. Recovery centers aren’t suitable for these individuals because they aren’t physically addicted, he says.

But professional counselors can help clients explore and recognize their problem use through exposure to motivational interviewing and the stages of change, Morgan says. Often, these clients have ended up in the counselor’s office because they’ve had trouble at work, at school, with their family or other relationships, or elsewhere. They may flatly deny any suggestion of “problem use,” but counselors can suggest exploring what is going on in these clients’ lives.

“If they’re willing, that already puts them into precontemplation,” Morgan says. Counselors can take that recognition that something’s not quite right and say, “Let’s look at what change looks like,” he suggests. “Let’s stop drinking, drink less or drink less harmfully.”

“We have to pay attention to moments of opportunity,” he stresses. “Someone gets pulled over for a DUI — that’s a moment of opportunity.” If someone is overdrinking and prone to accidents around the home, every visit to the emergency room is an opportunity, Morgan continues. Some hospitals are already using motivational interviewing for brief interventions in the ER, and the success rates have been impressive, he says.

The problem is that for too long, the message has been that when people with substance abuse problems are ready, they will seek help, Morgan says. But most of the time, they’re not going to come in on their own, he asserts.

“We have to raise the bar,” Morgan concludes.

 

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Additional resources

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 lmeyers@counseling.org.

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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.

Healing the healers: Counselors recovering from familial addiction

By Suzanne A. Whitehead October 8, 2019

It has been roughly 17 months since I wrote a piece for CT Online about my son’s struggle with addiction, and it is amazing how far he and our family have come since then. I felt compelled to write a follow-up, not just because he is my son, but also because in the past year, I have discovered that so many professional counselors’ and counselor educators’ family members suffer in silence.

Last year, I used an author pseudonym in my article. I did this for two reasons. First, out of respect for our son because he was still in residential treatment and I couldn’t ask him for permission at that time. Second, I wanted to preserve anonymity for both of us, afraid of the effects that discussing our story and revealing our identities might have. A lot has changed over the past year, however, and today, both my son and I are so much stronger for having the courage to speak out. We no longer hide behind the effects of this horrible disease. I have learned that by speaking up, the addiction no longer holds any power over our family. I hope in this article to offer some solace, support, understanding and love to those who are suffering in silence. We healers deserve to heal too, and my heart goes out to you all.

On Feb. 16, 2018, the police called us at 2:30 a.m. from the other side of the country — 2,600 miles away — to tell us that our beautiful, precious son had been found on the side of the road, passed out. We later learned that the heroin in my son’s possession had been laced with fentanyl–he had no idea. Heroin users never have any idea what they are truly getting. They assume it is the same product that they are used to, draw up the same “dosage,” and a few seconds after injection, it’s all over.  The police  told us  that they had found our son just in time. He was in the cab of his truck, his foot still balanced on the brakes, the heroin and needle next to his side, the tourniquet still strapped to his arm and accompanied by his faithful dog, who barked like crazy as the police pounded on the door. It is a miracle our son is still with us. It is even more miraculous that he now has over 14 months in recovery and in order to pursue what he calls his life’s work, is studying to become a substance abuse counselor.

I wish I could share with you the “miracle formula,”– a path that if everyone could just follow, they would be “OK.” If only … But, this disease of addiction doesn’t work that way. It has a mind of its own, and its victims must find the recovery that best works for them.

I attended the American Counseling Association Conference & Expo in New Orleans this past March and went to a session proctored by Geri Miller (author of Learning the Language of Addiction Counseling). She, along with two other presenters, Jennifer Kline and Ben Asma, tried to describe the nature of addiction to the audience: how tolerance builds up, how the brain becomes “hijacked” by the opioids, and the realities of withdrawal. They did an outstanding job  relaying what actually happens to a human being, and came as close as I’ve ever heard to describing the abject horror a person suffering from addiction must endure.

For those of us who have never experienced or witnessed a person in withdrawal (I am not a person in recovery, but am a licensed addiction counselor and professor who teaches addiction and counselor education), it is hard for people to truly understand its hell. My son had to go through it on the floor of a jail cell, writhing in agony. An addict no longer uses to get high – that ship has sailed a long, long time ago. They use only to avoid withdrawal.

When withdrawal starts, you begin to feel like you are becoming quite physically ill. Soon, you begin to sweat all over, then have uncontrollable bouts of freezing. Your skin begins to crawl; you start seeing double. Your gut aches as it never has. And then you begin to wretch violently.

Simultaneously, you lose control of your bowels, and getting to the toilet is no longer an option. The pain continues to grow as you lose the ability to stand up. Your stomach contorts and your head is in agony. You want to rip out your hair, your eyeballs, anything to make the wretched pain stop. You continue vomiting and soiling yourself, every few moments. There is no reprieve, no solace,  no hope. You are so “dope sick” now that you think you may die and loathe yourself so much that you no longer believe you are even worth saving. You know the one and only thing that will make this sheer hell on earth stop is if you can get some drugs in your system. You swear by all you have left within you that you will “quit tomorrow.” You must tell yourself this lie, because to realize that you can never quit on your own is too unbearable to fathom.

After several hours, or even a day or two of the above, you will do anything (just about) to get more drugs. You despise your very being, your reflection in any mirror, and the lies you constantly tell to the ones you love the most. Your shame and guilt seem insurmountable. Your spirituality is gone – it was one of the first things the drugs took away from you. There is no longer any hope, just the temporary relief of the heroin (or worse) coursing through your veins.

Each day, or several times per day, this hell is reenacted. Depending on tolerance, what you took, how often, withdrawals can start again in a matter of hours. When a person must detox without the benefit of using buprenorphine or a combination of buprenorphine and naloxone to slowly, medically and safely wean them off the substances, the hell can last for days or a week or more. Withdrawal from heroin use is rarely fatal; however, there are many serious side effects and people can die from dehydration. If they are not safely detoxed, their pulse often becomes thready, their PO2 oxygen levels drop, their blood pressure plummets and they may even slip into unconsciousness or start seizing. This is what happened to my son. The guards had to rush him back to the hospital after 36 hours to give him IV fluids. He was so gravely ill that he barely remembers this part. The hospital personnel patched him up and within a few hours, he went back to his jail cell. How we treat people who have unwittingly taken too much OxyContin and become victims of the pharmaceutical trade is unconscionable. It is now known that a person can become addicted to OxyContin within five days. And we treat these people, human beings, worse than wild animals.

To know my son survived this horror, alone, with nothing but Tylenol and something mild for nausea (which is vomited immediately), tears at the very fabric of my soul and violates all I hold sacred in this world. How he was treated was vile, but not uncommon. Many others who suffer from addiction and end up in jail receive the same treatment. They will face the legal system, as my son did, and pay for their crimes. But the horrendous lack of treatment, access to care or compassion, combined with the sheer inhumaneness they face, brings me to my knees. If people only knew…

There is no question that many people do horrid things when they become victims of addiction; the realities are painfully obvious. A cornerstone of recovery is the process of paying for  mistakes and learning how to make amends. Forgiveness from loved ones can come at a very heavy price, and forgiving oneself can ultimately become the hardest fought battle of all. Addiction is such a cruel, insidious disease, particularly because so many have such a difficult time in separating the behavior from the person. Understanding the horrible acts that some people commit, while also trying to see them as a person in severe emotional, physical and spiritual pain, is a significant and sometimes difficult juxtaposition. For those living with addiction, free will has been overtaken by the demands of withdrawal, and the self-deprecation that follows each usage is beyond daunting.

My intention in writing this piece is to help convey the utter destruction of opioid addiction and the ugly and purulent aspects of withdrawal. Once we truly understand this part of the disease, our entire paradigms change. It would be unconscionable to treat someone with cancer, heart disease, diabetes or emphysema this way. Yet we allow this to go on day after day after day. We lose over 116 dear souls to opioid overdoses in this country every day now, and the numbers continue to rise. We all share this plight because addiction can, and does, happen to anyone. Once we understand this, we can stop the blame and shame that has for centuries accompanied this disease and begin to proactively act.

Our son is still fighting this disease; he will for the rest of his life. So far, he is winning, but elements that test his recovery are always there. We continue to celebrate his victiories. The entire family went to his open Narcotics Anonymous meeting to watch him get his one-year keychain and cheered like crazy fools. The look of pride in his eyes said it all: it’s as if his life is now just beginning. He’s been volunteering 30 hours per week at a county outpatient and residential treatment center since September 2018 as he works on attaining his certification to treat those with substance use disorders. His compassion for those fallen is unparalleled; he “gets this.” His family couldn’t be prouder. What an incredible difference he is making in the lives of others every day. He is my hero, and I stand in awe of his contributions and bravery.

Narcotics Anonymous keytag (via newyorkna.org)

My other goal in writing this is to discuss the stigma that helping professionals face when our own loved ones confront addition. That reality persists, and when I feel brave enough to reach out, I have overwhelmingly found that so many others also suffer in silence. Because we are counselors, therapists, professors and educators, we—and others—believe that not only do we help heal others, we must somehow have all the answers and will always know and have the ability to intervene in cases of addiction — especially with our loved ones. The assumption (I surmise) goes that there is something gravely wrong with us when a loved one succumbs to addiction. Why didn’t we intervene and stop them? Unfortunately, it’s not a matter of becoming aware and then simply “stepping in.” Addiction is a bio-psycho-social-emotional disease, insidious in its approach, and deadly in its tracks. It is not exclusive and honors no perceived barriers — not religion, socio-economic class, ethnicity or any other categories or factors. Because secrecy, lying, excuses, stories, deception, and falsehoods are all part and parcel with this disease, even the most astute of us do not always recognize the signs of impending addiction. Before long, victims are well into their disease and, by necessity, the level of deception grows with each passing day. It’s called survival.

To blame the person who is addicted for using their survival instincts is antithetical to any help we can give them. So too is to blame the family members and loved ones, no matter their profession. The isolation I felt this past year was heart-wrenching, lonely, judgmental, sad, destructive, and purposeless. I have also found that this sense of isolation is shared by many of my comrades. I am mentally exhausted from hiding in the shadows, fearing recriminations and judgments from those who refuse to listen or understand.

As I test the waters and disclose our story, I am buoyed by the knowledge that there are so many of us who need a voice. We need to raise awareness that this disease knows no bounds and its victims are all of us. It’s time to stop letting addiction win. It’s time to stop being its unwitting counterparts. It’s time to treat the addicted person, the family, and the loved ones with humanity and compassion —- the same way we treat others with any type of potentially deadly disease. I’m determined to not let my professional colleagues suffer in silence. I feel your pain; I understand. Now, let’s get the word out.

 

 

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Suzanne Whitehead is coordinator of the counselor education program at California State University, Stanislaus. Her main research interests include promoting increased access and humane treatment for those afflicted with substance use disorders; crisis and disaster counseling; and equity for DACA recipients, immigrants and refugees. Contact her at swhitehead1@csustan.edu.

 

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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.

Infusing hope amid despair

By Laurie Meyers September 24, 2018

In 2015, two Princeton University economists, Anne Case and Angus Deaton, published a study in the Proceedings of the National Academy of Sciences of the United States of America that made a shocking claim: After decreasing for decades, the mortality rate for white non-Latinx middle-aged Americans was actually increasing. They ascribed this reversal of fortune in part to what they dubbed “deaths of despair” caused by an increase in alcohol abuse, opioid use and suicide. Their findings grabbed headlines and fueled furious debate in the public health and other research communities, particularly when they published a follow-up report in 2017 in the Brookings Papers on Economic Activity. Some researchers questioned the authors’ interpretation of mortality data. Other experts argued that the factors contributing to the rise in suicide rates and in opioid and alcohol abuse were too complex to be attributed to “despair.”

However, despite their narrow focus on a particular demographic slice, Case and Deaton were perhaps tapping into a greater sense of instability among the American populace. Since 2007, the American Psychological Association (APA) has conducted an annual nationwide survey — Stress in America — gauging both the overall level and leading sources of stress in the United States. The 2017 report revealed that two-thirds of the 3,440 adult Americans surveyed that August were significantly stressed about the future of the country. More than half of those surveyed — a group that spanned generations — said they considered the current time to be the lowest point in U.S. history that they could remember. Nearly 6 in 10 adults reported that the current climate of social divisiveness was a serious source of personal stress. Other significant sources of worry included money, work, health care, the economy, trust (or lack thereof) in government, hate crimes, conflicts with other countries, terrorist attacks, unemployment/low wages and climate change/environmental issues.

Although Americans may not be drowning in despair, research such as APA’s report indicates that many people are feeling more insecure than ever. That sense of walking a tightrope without a safety net can cause significant psychological distress, which can in turn lead to health problems and mental illness. Many experts say the burden of general societal unease is often magnified for disenfranchised groups such as communities of color or those of low socioeconomic status. And trauma — whether caused by being a member of a disenfranchised group or by a history of abuse or violence — takes an even more significant toll on health and well-being. Any or all of these issues may be related to the rise in opioid addiction and suicide across the U.S.

A poverty of health and well-being

To some degree, most people in the so-called 98 percent — those not in the top 1-2 percent of individuals possessing the majority of the nation’s wealth — worry about money: affording a mortgage, sending the kids to college, saving for retirement. The Great Recession may be over, but recent research from the Federal Reserve Bank of San Francisco (FRBSF) indicates that the economy hasn’t fully recovered. In its Aug. 13 economic letter, the FRBSF states, “A decade after the last financial crisis and recession, the U.S. economy remains significantly smaller than it should be based on its pre-crisis growth trend.”

The letter goes on to speculate that this is due to substantial losses in the economy’s productive capacity post-crisis. These losses were so significant, FRBSF researchers assert, that they could result in a lifetime income loss of $70,000 for each American.

This is staggering news for most Americans, but for those who live in poverty — 40.6 million Americans according to a 2016 U.S. Census Bureau study — such an amount is catastrophic. The poverty threshold is broadly defined as any single individual younger than 65 earning less than $12,316 annually and any single individual 65 or older living on less than $11,354 annually. The poverty threshold for two people under the age of 65 living together is $15,934, and the threshold for two people over the age of 65 living together is $14,326. For a family of three — one child and two adults — the poverty threshold is $19,055. For a family of three with one adult and two children, the threshold is $19,073.

For people who have never been impoverished, it can be difficult to comprehend all the ways in which poverty can affect health and well-being. Forget vacations, higher education and saving for retirement. People living in poverty are often unable to access basic needs such as safe shelter, food and, in some cases, even running water, says Chelsey Zoldan, a licensed professional counselor (LPC) practicing in Youngstown, Ohio. She has also counseled clients in the rural, impoverished Appalachian region of Ohio.

“I’ve worked with many clients over the years who have had their utilities turned off and lived in homes without water, heat or electricity,” says Zoldan, an American Counseling Association member. Missing that foundation at the bottom of Abraham Maslow’s hierarchy of needs, these clients struggle to stabilize their mental health symptoms, she explains.

People living in poverty often have to reside in low socioeconomic status areas with higher levels of violence and crime. Zoldan says many of her clients have lived in supportive housing and regularly heard gunshots in their neighborhoods at night. Although some clients seemed to get used to it, others — particularly those with trauma histories — had trouble feeling safe in their own homes.

Those who live in poverty also often lack access to quality health care. “Not only are individuals limited in terms of health care coverage, but they may also struggle to obtain transportation to get to health-related appointments,” Zoldan says. “In my area, there was such a high demand for medical transportation to appointments that they stopped providing door-to-door transportation and only provided bus passes.”

Instead of a 15-minute ride to appointments, Zoldan’s clients now had to navigate public transportation, which could take up to two hours each way with a change of buses. Riding the bus also poses another significant challenge — having to walk numerous blocks to the stop, which during winter in northeast Ohio means navigating “tons of snow” and double-digit subzero windchills, Zoldan says. Even in more clement weather, many of Zoldan’s clients were unable to devote two to four hours a day to traveling to health-related appointments, so they stopped receiving services.

Self-care can also prove challenging for those living in poverty, and it doesn’t include vacations or nights out. Zoldan works with individual clients to identify free activities that they enjoy and can engage in at least weekly, such as taking a bath, attending a Bible study, going for a walk in the park, meditating, and reading books or magazines at the library. Unfortunately, some of these activities may not be available to all clients, either because they live in rural areas with few resources or because they are unable to arrange child care, Zoldan points out.

Zoldan advises counselors working with this client population to get outside the walls of their offices. It is critical that counselors make community connections, she says, so that they can help clients access resources such as shelters, housing authorities, food banks, clothing providers, programs that offer financial assistance for utilities, medical transportation and vocational services.

“In connecting our clients with these resources, we can work to build a safety net for our clients and create some more stability in their lives so that they can thrive,” she says.

The legacy of racism

Racism happens on both a micro and macro level, says Cirecie West-Olatunji, a past president of ACA. Microaggressions are more nuanced and under the radar and involve everyday interactions with individuals who exert privilege. It might be the shop clerk who ignores an African American person in favor of a white shopper or a student of color who is consistently not called on, despite raising her hand. Macroaggressions are overt and meant to intimidate members of a group, such as neo-Nazis marching in the nation’s capital and people openly using racial slurs. Together, the macro- and microaggressions create pervasive, chronic stress that is handed down through intergenerational trauma, explains West-Olatunji, an associate professor at Xavier University of Louisiana and director of the Center for Traumatic Stress Research.

Over the past 20 years, researchers have been studying a phenomenon they first witnessed in some of the grandchildren of Holocaust survivors. Despite not having experienced the Holocaust themselves, and instead having grown up in a middle-class environment in the U.S., these individuals displayed survivor-like trauma symptoms. The findings were startling but have proved not to be unique. After 9/11, researchers studied children who had not been born at the time that their parents served as first responders at one of the attack sites. Like the grandchildren of the Holocaust survivors, these children of 9/11 trauma survivors displayed corresponding symptoms despite not experiencing the trauma themselves, West-Olatunji says.

Chronic, pervasive stress and trauma can be seen in changes at the DNA level, she says. Some researchers believe that these DNA changes play a part in handing down the trauma from generation to generation.

For African Americans, the trauma is also handed down on a systemic level, West-Olatunji says. “It is evident in social structures, education, lack of power and aggressive acts that threaten the psyche of individuals who are culturally marginalized,” she says. Slavery still casts a long shadow, its legacy evident in the school-to-prison pipeline, the number of African American children who are in low-resource schools, their overrepresentation in special education and the disproportionate diagnosis of behavioral disorders. “Children are being tossed out of the American dream by a lack of resources,” she says.

The effects of openly expressed racism are also manifesting in society, West-Olatunji says. “We’re anxious and irritable and feeling less hopeful about the world,” she says. These “symptoms” match those displayed by culturally marginalized groups.

Courtland Lee, also a past president of ACA, believes the effects of racism extend beyond the targeted group. In fact, he contends that racism can be considered a mental illness.

Lee began thinking of the concept of racism as mental illness after reading Stamped From the Beginning: The Definitive History of Racist Ideas in America, a book by Ibram X. Kendi that examines the intellectual roots of racism. Although many people may consider racism the purview of poor, white, rural Southerners, it has historically been handed down from the best and brightest minds in science, medicine, philosophy, religion and psychology, Lee explains. Racism is woven into our intellectual and social fiber and is used to manipulate people through fear of the other, he continues.

Lee says that targets of racist behavior are ground down by the constant micro- and macroaggressions, leading to “cultural dysthymia,” or collective low-grade depression. This collective depression is manifestly not conducive to mental health, and he argues that its effects aren’t felt solely by those who are targets of racism.

Lee believes that the fear and hatred of those who perpetrate racist acts is also mentally traumatizing — not just to those who are targeted but to the perpetrators themselves — and that the trauma must be addressed to treat the mental illness of racism. Counselors can do this on a systemic level through advocacy and on an individual level by helping people who are racist see that the agitation, irritability, hostility and hypervigilance they experience is caused by their beliefs. The challenge is getting perpetrators of racism to see that the defensiveness and fear inherent in racist thought can also bring those fears to life, Lee says.

For instance, one commonly cited reason to block immigration from Mexico is that these immigrants are stealing American jobs and damaging the economy. However, a lack of visas and fear of anti-immigrant violence have kept Mexican seasonal workers away from sectors such as the Maryland crab industry. In their absence, merchants who sell crab meat to restaurants and stores cannot recruit enough employees to clean and process their haul, even at high wages. That means the crabs cannot be sold, which is a major economic blow to the industry.

As a country, the United States needs to discuss racial issues, Lee says. Counselors, who are trained to encourage conversation, can and should facilitate these dialogues in their communities, through churches or community centers, he suggests. “We really do live in a sick society,” Lee says. “We can help people get well, but the only way to get well is to cure the society.”

As individuals, counselors can also play an important role in validating the experiences of people of color and speaking out when they witness micro- or macroaggressions, West-Olatunji says. She also urges counselors to explore non-Eurocentric methods, such as using the tradition of storytelling in the Latinx community or testifying in the African American community. Non-Western traditions can be applied effectively across cultures, making them a useful addition to any counselor’s toolbox, West-Olatunji says. 

Touched by trauma

“Life is a traumatizing experience,” says Cynthia Miller, an LPC in Charlottesville, Virginia, whose practice specializes in trauma. “It’s full of challenges, unexpected and uncontrollable events, and losses. I don’t think any of us gets through it unscathed.”

Miller, an ACA member, says trauma is on a spectrum that begins with ordinary stress and gradually progresses to completely overwhelm a person’s ability to cope. Eventually, it can even put them at risk of death.

A seminal study that the Centers for Disease Control and Prevention and Kaiser Permanente began in 1995 established a link between adult health problems and adverse childhood experiences such as emotional and physical neglect, sexual and physical abuse, exposure to violence in the household, and household members who had substance abuse problems or had been in prison.

These experiences fall on the more extreme end of the spectrum — often referred to as “big T” traumas. However, Miller cautions against discounting the “little t’s” as sources of distress. Where a trauma falls on the spectrum is individual and variable. “Some people might experience the loss of a job as stressful but wouldn’t be completely overwhelmed by it,” she explains. “Others might experience it as very overwhelming and become immobilized. So one person’s stressful event is another person’s traumatic event, and one person’s traumatic event is another person’s ordinary stressful event.”

Miller notes that mental health professionals recognize events such as the loss of a job, economic insecurity, divorce and family problems as sources of stress but often don’t accord them the same level of treatment as “real” mental illness. “It’s really a false distinction,” she says.

Someone who has lost a job or is going through a divorce is experiencing significant stress and is likely flooded with cortisol in the same way that a person who has experienced violence is, Miller asserts. “It’s really the chronic stress from either a ‘little t’ trauma or a ‘big T’ trauma that eats away at us and sets us up for depression, anxiety, anger problems, health problems and substance use,” she explains.

“There are a lot of things going on in society that could be experienced as traumatic,” Miller continues. “Globalization and automation are rapidly changing communities and workplaces, eliminating some industries and leaving workers scrambling for jobs that pay less and offer less job security. Economic inequality is growing, and housing costs keep rising. People feel increasingly insecure and like their futures are being threatened. That’s leading some people to feel helpless or hopeless. Others are angry and lashing out.”

Trauma-informed counseling is critical to recovery from both “big” and “little” traumas, Miller says, as well as for building ongoing resilience.

“I think that the biggest thing that trauma-informed counselors bring to the treatment process that less-informed counselors may not is an alternative explanation for behaviors that are often seen as purely manipulative, obstinate, oppositional, attention seeking or antisocial,” Miller says. “Trauma-informed counselors may be more likely to view a client’s reactions and behaviors as attempts to cope or protect themselves rather than chalking them up to resistance, treatment noncompliance or poor motivation. They also bring an awareness of the importance of creating a sense of safety and control for a client, and they work to create environments in which clients have as much autonomy and input into their treatment as possible.”

Miller also decries the traditional “split” between substance abuse and mental health treatment. Although she doesn’t believe that all substance abuse is caused by mental illness or trauma, she says these are often underlying factors that go untreated, which puts clients at risk of relapse.

Regardless of the cause, substance abuse is an illness that needs to be treated, she asserts. “For far too long, substance abuse has been treated as a problem of weak moral character rather than an effort to soothe emotional pain that someone doesn’t feel able to cope with,” she observes.

Miller also points to the contrasting public reactions to the crack and opioid epidemics. Whereas the crack crisis of the 1980s and early 1990s was considered a criminal problem, the current opioid epidemic is recognized as a public health problem, she notes. Miller ascribes this difference not only to the traditional judgment of substance abuse as a moral failing but also to the reality that crack was seen largely as affecting African Americans, while opioids are generally viewed as affecting white Americans. (Some researchers and commentators have also begun noting that the growing number of opioid-related overdoses and deaths among African Americans has largely been left out of the national narrative.)

Seeking solace

Just as crack enveloped areas that were economically devastated — at the time, predominantly African American urban neighborhoods — opioids are most common in rural areas that can no longer depend on the industries that once sustained them. West Virginia is one of the epicenters of the opioid crisis, and Carol Smith, an ACA member and past president of the West Virginia Counseling Association, believes that isolation and the lack of opportunity in much of the state are helping to fuel opioid abuse.

A frequently spun narrative of the crisis is that of unsuspecting people who get addicted after being prescribed opioids for pain after injury or surgery, but those cases make up a small percentage of those who are addicted to opioids, according to Smith. Indeed, people have been using opioids for pain relief for decades without becoming addicted on a large scale, notes Smith, a counseling professor and coordinator of the violence, loss and trauma certificate of studies at Marshall University. The people who do get addicted after being prescribed opioids usually already have substance abuse problems, she says.

However they first encounter opioids, the people most at risk for addiction are those who lack good coping skills and social support, Smith says. They typically also have a certain degree of existential despair, which is only reinforced by the long-term abuse of opioids.

Smith explains that West Virginia is particularly vulnerable to this sense of despair because its topography of mountains and waterways makes building roads and installing cables prohibitively expensive. This isolates the state not just physically but virtually because of the lack of high-speed internet access, she says. This lack of connectivity discourages new economic development, further reinforcing the cycle of poverty. As a result, many of the state’s inhabitants don’t feel that they have a lot to lose or much to strive for, Smith says, leaving them vulnerable to anything that might make the day go by faster or easier.

With its emphasis on treating the whole person, counseling is integral to the effort to stem the tide of addiction, Smith says. Counselors can help clients fight despair by guiding them to regain a sense of purpose through goal setting and identifying reasons for living. In addition, counselors can aid clients in dispelling their sense of isolation by teaching them relationship skills and helping them build support networks. Smith also stresses the importance of combining counseling with medication-assisted treatment, which addresses the physiological aspects of addiction.

Dying of despair?

According to the Centers for Disease Control and Prevention (CDC), 45,000 Americans 10 years and older died by suicide in 2016, the most recent year for which statistics are available. In the June CDC Vital Signs report, the agency said that from 1999-2016, the suicide rate rose by more than 30 percent in 25 states. While acknowledging that those suicide statistics are the most accurate figures available, the American Foundation for Suicide Prevention has stated that it believes actual rates are much higher.

Case and Deaton’s study connected the rise in the suicide rate in part to despair caused by a dearth of employment and lack of opportunity, but some experts say that causation is far from clear.

“It is hard to pinpoint a specific cause,” says ACA member Darcy Granello, a professor and director of the Ohio State University suicide prevention program. “Frankly, the numbers are increasing at such an alarming rate and across so many different demographic groups that we have to be careful not to paint broad brushstrokes and assume that specific factors apply to all of these different groups.”

Granello, whose research focuses on suicide prevention, does believe that Americans are feeling more isolated and disconnected, however. “That pervasive sense of loneliness is especially dangerous for those who already struggle with depression,” she says. “We know that social connectedness, feeling supported and having a sense of belonging all are protective factors that help minimize the risk for suicide. When those are taken away, suicide risk increases.”

Granello says myriad factors may be contributing to the rise in suicide, but recent research has caused experts to question their understanding of suicide. For example, historically, 90 percent of those who kill themselves have some kind of mental illness — often undiagnosed or untreated. However, more and more people who die by suicide do not have a diagnosable mental illness at the time of their death, Granello says.

“This is challenging to everyone in the field, and it causes us to rethink much of what we know,” she says. “It means that suicide is more and more the result of people who simply do not have the resources to cope with life’s problems, whether this inability to cope is because they are living with a mental illness or simply because they are overwhelmed by life and have never developed healthy coping strategies.”

Granello urges counselors to focus on helping clients develop those strategies. Those at risk for suicide are often ill-equipped to face life’s challenges, make long-term plans and envision a future, she says. For many people, the key to survival is getting through the crisis period — that window when they are most tempted to end their lives, she continues.

Counselors can teach clients to move out of their isolation, reach out to others and develop healthy coping strategies, Granello says. But to do that, counselors need to be adequately trained in suicide prevention, assessment and intervention — something that Granello doesn’t think is happening often enough. She stresses the need to push for comprehensive, empirically supported suicide prevention training in counselor education programs and through continuing education.

“We have to do this,” Granello says. “We are, quite literally, fighting for our lives.”

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Books and DVDs (counseling.org/publications/bookstore)

  • A Contemporary Approach to Substance Use Disorders, second edition, by Ford Brooks and Bill McHenry
  • Counseling for Social Justice, third edition, edited by Courtland C. Lee
  • Multicultural Issues in Counseling: New Approaches to Diversity, fifth edition, edited by Courtland C. Lee
  • Suicide Assessment and Prevention, DVD, presented by John S. Westefeld

ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources)

  • Trauma and Disaster
  • Suicide Prevention
  • Substance Use Disorders and Addiction

Podcasts (aca.digitellinc.com/aca/store/5#cat14)

  • “Counseling African-American Males: Post Ferguson” presented by Rufus Tony Spann (ACA285)

Webinars (aca.digitellinc.com/aca/pages/events)

  • “Traumatic Stress and Marginalized Groups” with Cirecie A. West-Olatunji (CPA24341)
  • “Dissociation and Trauma Spectrum” with Mike Dubi (CPA24333)
  • “ABCs of Trauma” with A. Stephen Lenz (CPA24329)

Competencies (counseling.org/knowledge-center/competencies)

  • Multicultural and Social Justice Counseling Competencies

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

 

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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.

The opioid crisis and a wounded counselor’s heart

By Antoinette D’Angelo (pseudonym) May 14, 2018

[Editor’s note: Because of the personal nature of the narrative, the author is using a pseudonym.]

 

“Welcome to the club!” This greeting, typically extended to new members, often implies certain advantages, discounts and perks. However, the club my husband and I unwittingly have joined is based on an experience I would not wish on my worst enemy.

We received “the phone call” — the one every parent dreads in their wildest nightmares — at 2:30 in the morning in mid-February. It was the police station calling to tell us that our son had overdosed. He was alive, barely, but they had found him just in time.

A tumult of thoughts raced through my mind. Our son lives 2,600 miles away. Could it be a mistake? Were they sure it was our son? He wasn’t supposed to be in that city. What is happening?

As I write this, I know similar words must have been said or written a million times over by so many other heartbroken parents. In truth, there is nothing new to read here. Yet, it is my son I am writing about, my “kid” (now in his 30s). It is my same son whom I desperately worried may not live when I went into labor at six months gestation. It is my child whom the OB-GYN gave only a 10 percent chance to make it. It is my child who did make it, who went on to do great in school, who had tons of friends, who graduated from college, who got married and had a wonderful job. It is my kid who loved cutting down Christmas trees when he was little, swam like a fish and played soccer until his feet ached. It is my child who loved our annual summer trips all across the country to see major attractions and visit dozens of national parks. And it is my son whom the police were now telling us had almost died of an opioid overdose.

I write this story partly for the cathartic release it provides. Our family has cried more tears over the past few months than we could have previously imagined possible. Perhaps more important though is this: The ultimate irony of this situation is that I am a licensed mental health counselor, a licensed addiction counselor and a master addiction counselor. I am an assistant professor of counselor education and teach courses in addiction and treatment. I “know” so very much — maybe even too much on paper — about this disease of addiction, while simultaneously finding that I know so very little.

 

A quest for treatment

A few hours later, we raced to the airport, my husband catching the first available flight to the East Coast. We decided that once my husband got more information, I would fly out. Unfortunately, his plane was delayed, he missed his connecting flight and he ended up arriving after midnight. With no “new” news about our son, the hours ticked by excruciatingly slow.

The next morning, my husband went to see our son in jail — the words still seem incredulously stark written here. They brought our son out in a wheelchair. He was retching violently, trembling uncontrollably and could barely speak. My dear, sweet, gentle husband wept because he thought our son, who was in full-blown detox, was going to die. My husband and son could talk with each other only through a television screen. After 10 minutes, they took our son away.

I called the jail shortly thereafter and pleaded to find out what was happening. The response was that they weren’t allowed to tell me. Many hours later, I was routed to an “angel” sergeant who explained the jail’s “detox protocol” — they give the inmates Tylenol and a pill for nausea, but the inmates throw that up immediately.

Our son was in sheer agony, and we had never felt so utterly helpless in our entire lives. We could not even get a message to him. The whole experience shook us to our cores, and we felt nearly incapacitated by immobilizing grief.

My husband had his “one allotted visit” for the week, which was on Saturday, meaning that the next visit couldn’t be until Monday. We were distraught with worry about our son’s condition but weren’t allowed any additional information. We contacted an attorney in the area whom we had worked with previously years prior. Blessedly, he took on our son’s case but was likewise unable to find out anything over the weekend — and Monday was a holiday. Our agony continued, piercing our souls.

Tuesday was the bond hearing. Our son had been charged with two felonies and two misdemeanors. Our attorney spoke on our behalf. Amazingly, our son was released from jail in our recognizance, as long as he agreed to go directly into treatment.

The next several days were a blur-filled nightmare that involved navigating the quagmire of insurance situations. We found that because our son was “five days sober,” no detox unit would take him, reasoning that he was not in quite desperate enough straits at that point. No residential treatment center would take him; he didn’t qualify for Affordable Care Act insurance because he had lost his job. He couldn’t get on Medicaid because his physical address was listed a state away. We couldn’t get the best insurance money can purchase because he had a pre-existing condition. Our son was still in a very fragile state, with double vision, horrible stomach pains, crawling skin sensations, major sleep deprivation and continuous hot/cold sweats. He needed help — fast.

With no other viable options, our attorney managed to get an emergency stipulation granting my husband permission to drive our son the 2,600 miles across country to where we live. Meanwhile, I had stayed at our home, spending countless hours investigating insurance options and trying to find a residential treatment center for our son. My husband drove as he never had in his life, making the trip in three and a half days. They arrived in the middle of the night, our son a mere shell of the vibrant, funny, creative, loving soul that he once was.

We signed our son up for Medicaid in our state, which featured a 45-day backlog. We could request emergency consideration, with the possibility of them meeting us within 48 hours, but there was no guarantee. Our son would have to be assessed, and then there was the issue of actually finding him a bed at a residential treatment facility.

I must have contacted at least 25 treatment centers; none would take Medicaid. So there our son languished. We watched him slipping away from us as he struggled with his new sobriety and no treatment. If our son had been suffering from any other “acceptable disease,” waiting to obtain treatment would have been deemed unconscionable and cruel. From my view, it is beyond words that we ask those who suffer to simply bear their pain and deal with it.

I emboldened myself to share the situation with some trusted co-workers. The disease of addiction is still fraught with stigma, but I was so beyond that now, knowing that if we didn’t find something soon, the agony our son was experiencing would lead him to the streets. Human beings can withstand only so much pain. He was attending 12-step meetings as best he could but was so weak, it was hard for him to focus. He was more than ready for treatment and begged us to help him find something. He was simply too ill to do this on his own.

Through the grace of a co-worker, I was able to contact a treatment center that a relative of hers had attended with great success. I called, and we made an appointment the next day. The center took only private insurance, but we had already explored every other possibility. There were no other viable alternatives. It caused us to ponder, what does a person do who has no access to health care? (And, thus, all the overdose headlines!) We brought our son in for an intake assessment, and three hours later, he was in detox treatment; the timetable was for 35 days.

 

 

An equal-opportunity disease

Our story is merely a reflection of the countless individuals now suffering from our nation’s opioid crisis. Tragically, a huge percentage of those addicted are not so lucky as our son has been to have survived. Our son has an unfathomable journey ahead of him to maintain his sobriety. The shattering statistics confirm that only about 10 percent of individuals who are addicted find treatment — perhaps half of them will remain sober.

Our son’s addiction to opioids started as many others have. He had a back injury at work a few years ago, and his doctor prescribed OxyContin. Our son found some relief from the back pain but, more insidiously, found that it also helped with his longtime struggle with depression. Alas, he was a sitting duck. When the pills were gone, he tried to get more from the doctor, to no avail. He finally asked a friend, who led him to someone who had a few, and the rest is history.

On the streets today, one pill of OxyContin can cost as much as $60; a bag of heroin costs $5. There is no mystery why so many turn to heroin — not to get high but rather to relieve the impossible, all-consuming withdrawal. My son told us he tried countless times to overcome “the beast” on his own. The longest he made it was two and a half days — two and a half days of wretched, skin-crawling, vomiting, horrible agony. And we wonder why so many people are addicted. We treat people like criminals just for self-medicating their pain. We seldom think of them as even being human anymore, deserving of immense care.

As I tell my counseling students all the time, addiction is an equal-opportunity disease. I’m not a person in recovery, but I have attended dozens of 12-step, self-help meetings through the years. I worked as the program director of an outpatient substance abuse clinic for 10 years, often accompanying colleagues to open meetings so that I could honestly recommend them to my clients, know what they were all about and for the knowledge of “keeping it real” (that last one is crucial to me as a counselor and an educator.)

When I teach addiction courses, I ask my students to attend at least two open 12-step meetings if they are not seeking their own recovery but are there to learn, or two closed meetings if they are there to help themselves. They come back to class and share their experiences, which are often incredibly humbling to hear. They include tales of feeling embarrassed, finding it hard to enter the buildings, driving around several times looking for the courage to go in and acquiring sincere admiration and respect for those in recovery who have survived and share their journeys with others. The textbooks we have are tremendous, but nothing replaces the personal epiphany one can attain by witnessing these 12-step meetings. Many students have shared the sentiment, “There but for the grace of God …”

 

Holding on to hope

My irrational side tells me to beat myself up. I have been blessed with all this incredible knowledge and insight as a counselor and still did not know what my son was going through? I have refused to do so, however, not only because I realize that now is not the time for recriminations, but because I fully comprehend that addiction is a baffling and cunning disease.

It all makes sense now, of course — the endless need for money to pay for mysterious car breakdowns and vet bills for the dog, the many trips to see doctors for a once very healthy and fit young man, the horrible pain he was experiencing when his marriage fell apart. We wondered, of course, but were too far away to verify. We spoke frequently with our son but saw him briefly only three times over the past three years. Meanwhile, his addiction truly began to escalate.

It does no good to wallow in self-pity. It is just as futile to assign blame and fault. Pain, hurt, anger, frustration, desperation, sorrow, fear — all of these, and so much more, are ongoing and understandable. However, the one thing this disease cannot take from us is hope. The rational side of my being knows about evidence-based treatments, what has the best outcomes for success and what needs to happen.

In that sense, it has made things much easier for our family to endure because all of what is unraveling is in the range of “normal,” and that brings great solace. Our family is attending family counseling, going to Al-Anon meetings, reaching out to trusted friends and relatives, and realizing that we are so incredibly not alone. Still, it amazes me that if we were to tell a friend that our son has cancer, heart disease or even HIV, the response would be more understanding, more forgiving, more helpful. We have come light years in the field of addictions during the past two decades (I know — I teach this stuff!), yet we remain in the Stone Age as far as acceptance, understanding, scorn, victimization, blame and judgment go.

My hope is that readers will find some comfort in this writing (counselors are human beings first, with real-life crises of their own). I have found that addiction is an immensely alienating and isolating disease. So many people believe it will not happen to them or their loved ones because, after all, the person does decide on their own to pick up that first drink or drug, right? However, no one ever sets out in life to become an addict of any kind.

As human beings, our physiological needs are the most basic and supersede all others (refer to Abraham Maslow’s hierarchy of needs). We want relief from our physical/psychological/spiritual pain now and resort to self-medicating on a regular basis. I often ask my students, “What is your drug of choice? Is it caffeine, tobacco products, shopping, gambling, exercise, relationships, etc., etc., etc.?”

The point is, we are all slaves to our prefrontal cortexes, and once we find something that works for us, we make those lovely endorphins, the “intermittent positive reward” phenomenon takes hold, and we get positively rewarded for repeating that behavior. We are masters at conning ourselves into believing that the consequences of whatever we rely on continue to be far less than the rewards. And slowly, insidiously, the disease of addiction takes on a life of its own for far too many.

 

A time to take action

We know the physiology behind addiction. Those of us in the field screamed our warnings regarding OxyContin when it was first introduced in the late nineties. It didn’t require a huge knowledge of biochemistry to recognize the effects; its victims were immediately seen and affected so devastatingly.

Addiction professionals continue to scream from the highest pinnacles about the high potentiation for addiction from these drugs; we portended this epidemic well over a decade ago. And yet, here we are, still screaming of the dangers even as countless individuals are prescribed these drugs daily.

In 2017, the Centers for Disease Control and Prevention estimated that more than 115 people die every day due to opioid overdoses. I am not blaming the pharmaceutical companies (though perhaps I should?) or the physicians. Their ultimate goal (one hopes) is to adhere to the Hippocratic oath, to do no harm and to relieve human suffering. However, I believe that we have reached a tipping point, as Malcom Gladwell described in his book of the same name. Our nation is realizing that this crisis affects our mothers, our fathers, our sisters, our brothers, our daughters, our sons, our relatives, our friends, our co-workers, our ministers, our doctors … and ourselves.

The #MeToo movement has shown us the time for action is now. The #TimesUp movement is doing the same. The #NeverAgain movement is gaining immense momentum. It is time for our passions, our sensibilities and our combined courage to demand more research and increased access to treatment. It is time to get over our fear, ignorance and blame regarding addiction. And we need, once and for all, to acknowledge that the disease of addiction is happening at lightning speed all around us, with no letup in sight.

There is no time to waste on blame or recriminations; we need to act. Addiction can take hold of any of us, regardless of our training, our background, our socioeconomic status or our rationale. It happened to my son, despite all of the knowledge I possess as a counselor.

My fervent belief is that with understanding and proper intervention and treatment, we can more readily help those who are afflicted. More importantly, I believe we need to get at the real root of why people need to self-medicate in such powerful ways. We knew our son had problems with depression. He attended a few counseling sessions over the years, but there was no incentive to stay, and even taking the step of seeing a counselor came with perceived stigma. We all have the power to change the paradigms around this.

As of this writing, our son is more than 60 days clean and counting. He has completed his residential treatment and is living with us, taking it one day at a time and trying to deal with life on life’s terms. The neglect of his overall health has taken a huge toll, but together, we are trying to slowly repair its ill effects. This will definitely take time, but the joy is that now we do have that precious commodity.

My message to all my dear counselor colleagues is this: This disease affects all of us. The palpable pain of our nation is excruciating, and we are all awash in its collective anguish. As a nation, we must reach out, not suffer alone. We need to find hope, discover solace and all begin to heal. We also must find the profound courage to act and change our national discourse and paradigms on how we view and treat people who are self-medicating in hopes of finding relief from traumatic pain.

As counselor change agents, we can do this! There can be no higher calling. #EndOpiods.

 

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Antoinette D’Angelo is the pseudonym for an assistant professor of counselor education teaching in a university in the western U.S. She is a licensed mental health counselor, national certified counselor, master addiction counselor and licensed addiction counselor. She has worked in the human services/counseling profession for over 44 years. Her research interests include substance abuse and trauma treatment; crisis and disaster counseling; counselor wellness and alternative holistic treatment methods; and immigration, DACA, and refugee assimilation and reform.

 

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For more, see a follow-up article from this author: “Healing the healers: Counselors recovering from familial addiction

 

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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.