Servant of the Process: Team v. individual approaches in drug treatment

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What process? You mean the process of addiction? Do you mean the process of working with teens in a rehab setting? There are several elements of Working Through Rehab: An Inside Look at Adolescent Drug Treatment, that bear explanation. One of the more important features is this whole question of whether to treat the substance dependent individual (teen or otherwise) through a team approach or through the model of individual therapy. In a hospital-based drug treatment program, professionals assert that they work as part of a team which may include a variety of collateral contacts, each of whom may come from differing disciplines: therapists, teachers, doctors, psychiatrists—you get the point. If not characterizing a team approach, practitioners may use synonymous language, and describe their work as “systemic”. Among other things, it means that information drawn from patients, in individual, family, or group therapy formats, is shared with all members of a treatment team, in or outside of a program. The idea is to contain destructive behaviors, including but not exclusive to the addictive use of substances, and to uncover discrepancies in reporting by the patients. The premise is that addicts lie so the information they share with individual therapists is not reliable. As a result, traditional rules of confidentiality are loosened, especially with patients mandated through legal authority, such that the priority task—interrupting problem behavior—is more likely achieved. The argument goes something like this: since patient disclosures are unreliable, the traditional ethos of treating disclosures as sacrosanct is misplaced. Therefore, in a hospital or group home setting wherein therapists are operating from a “team approach”, individual counseling sessions aren’t really what they appear to be. There are invisible parties in the room.
For the most part, I have supported this therapeutic stance, especially on occasions (more numerous than not, actually) when it seemed obvious that patients were not truthfully reporting either cravings or continued using behavior. It has often seemed that if programs are to really intervene with a pattern of drug use, then it is necessary to maintain a skeptical position with a patient; to not get caught up in a patient’s denial system, and to consult with others—in short, to not get fooled. To work in a rehab setting and learn the ropes is to have the experience of being played by slippery drug addicts, over and over again, until this lesson is learned. Problem? To share information with colleagues and collateral contacts risks stalling or undoing the fragile trust-building that all therapists must achieve with their patients. So what, I hear the average drug counselor saying, especially those of the so-called old school variety. That trust-building isn’t happening anyway, they’d argue. After all, it is the addict, not those who live or work with them, who fail the exercise of trust. It is they who fail to trust others, family, friends, and helpers, by repeatedly not sharing the truth.
These are sound arguments that routinely bully therapists who otherwise hope to not waste their time with reticent, untrusting patients who will likely resist the spirit of help being offered. Despite my overall support of the “addiction model” ethos, I nonetheless think the arguments of individual therapists, particularly those working outside the addiction model, make compelling counterarguments regarding the loss of confidentiality. From this tradition, derived from a plethora of psychoanalytically oriented therapies, the patient in therapy must be assured that their disclosures will be treated confidentially. To do anything less would compromise trust and inhibit disclosures, rendering therapy an exercise in compliance—not meaningfully different from a relationship with a teacher, probation officer, or some other obvious figure of authority. Trust-building is a long-term task that can and should transfer to personal relationships, enabling meaningful dialogue about difficult subject matter over a lifetime. Trust-building isn’t simply a therapeutic nicety that will allow a therapist to have cordial exchanges with a reluctant patient. Secondly, and perhaps most interestingly, some argue that the containment bias of addiction model proponents sets up an artificial situation, one that is ultimately unhelpful to addicts and their loved ones.
To explain: one of the most difficult things for a loved one to say to the addict is something like “I don’t believe you. I think/feel you’re lying.” Fundamentally, it feels unempathetic and disrespectful to confront someone in this manner, and therapists usually feel a parallel dilemma: how to confront with tact while not rupturing the therapeutic bond. Paradoxically, many therapists have found that when they do confront lying behavior in patients, tactfully or not, it often improves the bond as opposed to disrupting it. Some of the best moments at Thunder Road occurred when committed staff, on the back of a solid bond with a difficult kid, pronounced its belief that the patient/addict was lying. This action, fraught as it is with anxiety and risk, enables the therapist to more fully empathize with the oft-gaslighted loved ones of addicts, those whose entire lives seem to revolve around similarly painful dilemmas: what can I say when my gut tells me something’s not right? What’s the easiest way to say I don’t trust you, don’t believe you?
No model of care is perfect or even close to being perfect. Addiction models and traditional psychotherapeutic models are not mutually exclusive, and don’t believe anyone who tells you they have evidence of what works and what doesn’t. They’re lying.

 

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