What to Look For in an Addiction Counselor Part I
- A young man who comes from a dysfunctional family is told by his counselor (in front of a family group), “You’re a pathetic liar,” after he shares details of his past including what he perceives as the roots of his anger.
- A woman in residential treatment for an alcohol use disorder is forced to attend a lecture on eating disorders despite objecting that it might conjure up painful feelings because she’s in remission from an eating disorder.
- A man obliges his counselor’s request to complete a personal relapse prevention plan but upon presenting it to her, she pulls from her drawer her own “generic or near generic” (his words) plan for him.
- A woman tells me about going to a treatment facility at which people are made to stand in front of others to have their “defects” reported to them and are sometimes made to wear derogatory signs around their necks.
Few people would accept this kind of treatment from a classroom teacher, religious leader, medical professional, or any other helping professional. Why would we tolerate such behavior from addiction counselors? Yet all examples were shared with me during or since my writing of Inside Rehab.
Typically, individuals who go to residential rehab or outpatient treatment are “assigned” to a counselor, not realizing that if they don’t “click,” the outcome is unlikely to be optimal. One of the most striking findings in research on treating substance use disorders is that how well clients do in treatment differs dramatically depending on the counselor to whom they’re assigned.
Clients are the Consumers
Clients need to see themselves as consumers and assert their right to work with counselors who will best meet their needs. What counselor qualities are likely to serve in someone’s best interest? (I would seek the same qualities if seeking an individual substance use disorder counselor – for instance, a psychologist or social worker who specializes in this area.)
- Displays Empathy
Substance use disorder psychologist Reid K. Hester, Ph.D., Director of the Research Division and Senior Science Advisor of Checkup & Choices LLC, said, “The research is clear that the most important characteristic of counselors that is predictive of outcome of their clients is empathy.”
In short, empathy is the experience of understanding others from their perspective. Empathic counselors are able to place themselves in their clients’ shoes and feel what they are feeling. Such counselors also have the ability to convey what they hear back to clients to make sure they have the correct understanding. (In their book, Treating Addiction: A Guide for Professionals, authors William Miller, Alyssa Forcehimes, and Allen Zweben stress that empathy is not the ability to identify with clients by virtue of having had similar experiences – in fact, personal recovery status doesn’t influence success in treating people with substance use disorders one way or the other.) At his website, William Miller a prominent psychologist who has studied “therapist effects” in substance use disorder treatment, summarizes research on the topic noting, “The better therapists were at listening to their clients, the more their clients changed.”
In contrast, less empathic counselors’ clients tend to not do as well. Even in studies in which counselors provide clients with the same manual-guided treatment, they vary in their effectiveness. What accounts for the difference? Study after study reveals that the key is empathy.
- Is Nonconfrontational
In contrast to the benefits of being empathic, Miller notes one study in which researchers were able to predict drinking outcomes over one year after treatment from a single therapist response during treatment: “the more the therapist confronted, the more the client drank.”
Tracing the history of confrontational approaches in addiction treatment in an article in Counselor magazine, William L. White, M.A. and Dr. Miller cite multiple studies showing that confrontational approaches are ineffective and can be harmful. They note that that accusing, confronting, labeling, and demeaning people may cause defensiveness and thereby appear to confirm stereotypes about those with substance use disorders such as being “in denial,” dishonest, and oppositional. White and Miller stress that science does not support the notion that there’s a unique “addict personality” wherein people with drug and alcohol problems display such characteristics – in fact, research shows that such individuals are extremely diverse.
- Collaborates With You in a “Client-Centered” Way
In Treating Addiction, the authors stress the import for counselors of using a style with clients that “communicates not ‘I have what you need,’ but rather, ‘You have what you need, and together we will find it.’” A good counselor will also teach new skills, provide guidance, make suggestions, and provide experience but in that context allows you to make your own decisions.
Unfortunately, many treatment programs have a predetermined “program” that varies little from one client to the next – some people I interviewed referred to this as “cookie-cutter” approach. One woman who went to a very prominent residential facility said she looked around at what her roommates were doing at night and found, “We were all doing the same homework.” Another young woman who went to the same facility just recently told me what her personal treatment goals were – however, none of her goals appeared on the treatment plan her counselor came up with. In contrast, at an outpatient program I visited where clients were not coerced to do anything and instead were given choices, one of them told me the upshot is, “You’re more comfortable, more likely to tell the truth if you make a mistake.”
In short, a good counselor “meets you where you’re at”, guides you in a gentle and caring way, involves you in setting your own treatment goals, allows you to switch counselors if desired, encourages outside support that best meets your needs (for instance, allows for options other than 12-step), and changes goals that aren’t working.
Meeting Your Needs First
A 2009 review of studies published in the Journal of Clinical Psychology indicated that clients matched to their preferred treatment were about half as likely to drop out of treatment and had close to a 60 percent chance of showing greater improvement when compared with clients not given a choice.
A staff member at an outpatient program I visited rather snidely told me the most common resistance he encounters in treatment is “terminal uniqueness.” He described this as an attitude of “I’m different; no one understands me; that might work for them, but it isn’t going to work for me.”
In one fell swoop this demonstrates lack of empathy when clients feel their needs aren’t being met; a confrontational attitude by labeling and generalizing about a group of people; and a noncollaborative nature by failing to recognize that every person with a substance use disorder is unique with individual needs that should be met by a personalized plan, taking into account what the client expresses as needs and concerns.
Dr. Miller told me, “People do have hunches about what will work best for them. And those who choose from among options tend to ‘own’ what they’ve chosen and stay with it. So why would you not let clients choose? If one thing isn’t working, you can try something else.”
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