Relapse: our dirty little secret

Even this is a misleading question as we speak of relapse for recovering counselors but not of other behavioral concerns for non-recovering counselors, such as significant weight gain, return to tobacco use, stress-related illnesses and other behavioral addictions. Do we treat all staff the same way, regardless of their recovery status when there is abusive use of substances?

Most agencies, at least in the past, have had policies stating that staff in recovery must have at least two years of abstinence from substances. I am not a lawyer, but I'd suggest this policy is illegal because it discriminates against the recovering person. I believe the policy ought to read that all employees must have two (or more) years of non-abusive use of substances. This levels the playing field and treats all personnel equally, regardless of recovery status. And if we're not sure what “abusive use of substances” means, check the DSM-IV-it's clear.

Issues to consider

However, of late I am questioning for myself even this policy. Here are some questions for a clinical supervisor and management to consider:

1. Do we treat all employees the same? Do we hold management to the same standards as line counselors, especially if management does not provide direct care? How do we deal with “ancillary personnel” such as housekeeping, drivers, counselor aides, etc.? Do we make exceptions if an employee is deemed “too valuable” to an organization to lose because of abuse of a substance?

2. We say addiction is a disease of relapse, like other chronic illnesses. Patients have individualized treatment plans to address potential relapse. In some programs, when a patient relapses while on a weekend pass (or should I call it a “lapse”?), the treatment staff assesses the potential for continuing treatment on a case-by-case basis. Shouldn't we do the same for staff when they lapse?

3. George Vaillant, the grandfather of addictions, says that when you treat a disease without a cure, treat it with hope. Hope is a memory for the future. What hope do we offer staff when we automatically terminate an employee because of an abusive use of a substance, or other forms of relapse? Wouldn't it send a more powerful message about what we believe about the disease of addiction if we considered each situation individually to determine what's best for the person, rather than having a blanket policy of termination?

4. Are we consistent in our approach to various lapses? I know of an agency where a counselor aide in recovery relapsed and was disciplined for that, while a counselor “relapsed” into chain smoking by his self-report. Another counselor was described as “unpredictable, volatile, angry and paranoid.” Do we treat substance abuse differently because of the nature of our services, and should we? How do we deal with personality disorders, eating disorders, tobacco use? Does this inconsistency in our actions reflect a deeper-rooted stigma about substance use?

5. Now here's the big question. Most healthcare disciplines (nursing, general medicine, psychology, etc.) have “impaired professional” programs to rehabilitate personnel with problems. In the addiction field, some states have such programs, but most don't. There is, to the best of my knowledge, no national service available to impaired counselors. Why not? What does this say about our attitudes toward substance abuse counselors? What help should we offer an impaired professional in our field?

6. How frequently does relapse occur in the field, and why don't we know?

7. How do we communicate to other staff and especially to patients about an impaired counselor?

Re-examining policies

I am not opposed to rules and policies. They help us to organize our lives. Some rules are central to who we are and what we do, such as no sexual contact with clients. Some rules evolve over time, such as the policy requiring a patient who immediately relapses after care to wait for a period of time before readmission is considered. Most rules are frequently reviewed to reflect changes in attitudes and the understanding of what we are treating.

Supervisors, we need to re-examine approaches and policies that may have become “sacred cows” concerning lifestyle issues, including use and abuse of substances (including tobacco and prescription medications) and behavioral issues. Are we to hold the addiction counselor to a higher standard than we might with other healthcare professionals? And if so, how do we address these standards in offering help to the “impaired professional”?

There is, to the best of my knowledge, no national service available to impaired counselors. Why not? What does this say about our attitudes toward substance abuse counselors?

Here are some issues for us to consider:

1. Are our policies illegal or might they be deemed discriminatory in any way? Are our policies fair and balanced? Do we treat all employees the same or do we set higher standards for counselors?

2. Do we “walk the talk” when we consider addiction a disease of relapse?

3. Are there alternatives to termination that we might consider, such as referral to an impaired professional program or an employee assistance program (EAP)? Can we establish a course of recovery for the impaired professional, with strict standards to be followed before the individual can return to full responsibilities? Can we afford to sideline a person while he/she gets treatment?

4. Should we treat staff on a case-by-case basis in disciplinary actions?

5. If we are treating a disease without a cure, what hope do we offer the person?

6. And now for the big question. What is our obligation to patients? What messages do we want to send to patients about relapse? How can we demonstrate hope to them?

This is a long-overdue discussion for the field. I encourage a dialogue at the local, state and national level among treatment professionals and agencies on this issue. I encourage study and research into the nature and extent of the issue in the field. It's time we brought into the light our dirty little secret.