Complex patients deserve more compassionate care

It is exciting to see the progress the behavioral health field is making in services and service delivery. We have many ways of addressing substance use as well as other psychiatric disorders. We have grown and stumbled as we have continued what at times has been an arduous journey in figuring out what is or isn't effective in alleviating suffering and increasing functionality for complex clients/families. Substance use disorder services continue to evolve, starting long ago with self-help groups in response to multiple inpatient psychiatric hospital detoxifications and progressing to therapeutic communities to 28-day inpatient programs to short-term outpatient treatment to medication treatment to many variations of all of these. We can be proud of the progress we are making.

However, we are still experiencing growing pains. One area in which outpatient substance use disorder services has lagged behind the treatment of other psychiatric diagnoses involves minimum requirements for participating in clinical services.

Particularly, I have not seen or read much about efforts to engage clients and their families voluntarily seeking services, especially while they remain symptomatic (while they are still using/drinking). When this has been proposed, it has been argued against by many factions, including service providers, criminal justice/law enforcement professionals, child welfare agencies, families, faith communities, funding sources, etc.

Generally, on a day-to-day basis treatment staff are told to ignore these ideas and to continue to do “what worked for us.” Many are told, “I got into recovery this way, so it will work for these clients too.” In the face of this, and in many cases in spite of it, harm reduction and recovery-oriented philosophy and services have pushed the field toward efforts to engage clients/families who are living with the ongoing challenges of using, drinking and/or co-occurring disorders. This is an effective and much-needed approach to service delivery.

Still, the overall philosophy of substance use disorder services is that clients must be asymptomatic or not drinking/using. Unlike treatment of any other psychiatric disorder (schizophrenia, bipolar disorder, major depression, etc.), the outpatient substance use service delivery field maintains policies and practices that ask people to stop exhibiting the symptoms for which they want treatment before entering treatment. Then we will treat these symptoms that they have in partial remission. Also, the client may have to leave services when displaying symptoms (using/drinking), and/or the staff may label the person as “ not ready for recovery” when he/she does not succeed at being asymptomatic while receiving these services or after discharge, basically for the rest of his/her life.

Instead of decompensating (a common experience in ongoing recovery for all other psychiatric disorders) and then stabilizing again with the support of a voluntary and accepting service delivery staff, the client “relapses” and starts using/drinking again. We often tell the client that he/she will have to leave services for being too symptomatic of the illness, but that he/she can come back after becoming asymptomatic on one's own or at self-help groups. We then negatively judge the person upon return for having had symptoms and failing to stay in recovery.

My own transforming experience

Due to several factors, I decidedly turned away from this philosophy/approach more than 25 years ago. Since that time, I have seen hundreds of clients and their families become more functional and less symptomatic as they learn to live with substance use disorders (and more often, co-occurring disorders). I see them in my private practice as a family therapist and in publicly funded treatment services.

The vast majority of these clients come voluntarily, pay their bills like all other clients, cancel appropriately and reschedule new appointments. This population includes parents, adolescents, lawyers, police/correctional officers, physicians, truckers, pastors, brothers, sisters, teachers, business owners, wealthy/poor, educated/less educated, various cultural/ethnic groups, developers, construction company owners, nurses, occupational therapists, professors, and many others.

In 1991, I stopped using the old model. This occurred because of a simple yet profound interaction with a client.

I had terminated services with this client after I found out he was under the influence of alcohol during a session. I explained to him that I could not treat him while he was drinking because he was not able to participate rationally in psychotherapy if under the influence. I told him to stop drinking and then I would be happy to see him for therapy. He was crying when he left and said he would come back when he was sober. He never came back.

I remember driving home that night asking myself if I would have done that for any other psychiatric disorder. I realized quickly that the answer was no. I would never do that because symptoms are part of the psychiatric disorder presentation. I needed to see the symptoms to diagnose and treat someone with any other psychiatric challenge.

I would expect to see a depressed mood, congruent or incongruent affect, and other variables to make a diagnosis of major depressive disorder. I would want to know how long the symptoms had been occurring and if they had ever stopped, and if so, when and how. I would never ask anyone else to leave because they were symptomatic.

I vowed that night never to turn anyone away again with substance use symptoms. I remember thinking I might go to “substance abuse hell” for breaking one of the “commandments,” but I didn’t care. I quietly declared that from that point forward I would work with clients/families when they were symptomatic and help them achieve their goal of symptom management, whatever that meant for them. I would treat their psychiatric challenge that is deserving of effective treatment, similar to how other psychiatric challenges are treated.

Surprisingly, I came to see that I already knew how to do this approach. I had been using these skills for all other psychiatric challenges since I started my career. Although it took a while to experience a sense of confidence in interacting this way, I already had the skills I needed to treat those living with the challenges of substance use or co-occurring disorders. I knew how to be respectful, to treat them with dignity, to display unconditional positive regard, and to accept this normal person/family with one or more psychiatric challenges. I knew how to assist them as they worked toward their goal of symptom management or recovery as they defined it for one or multiple disorders.

Scenario in training

In my roles as a teacher and trainer as well as a clinical supervisor, I have asked many to consider what can occur using the traditional substance use service model to address other psychiatric challenges. It is an enlightening process. For example:

• Using the substance use model for any other psychiatric disorder, clients would be asked to leave when they are symptomatic and come back when they are not impaired by their symptoms so that they can participate in therapy.

• Using the substance use model for any other psychiatric disorder, we would build a predominantly inpatient delivery system to accommodate the “depression war” or “psychosis war” or “anxiety war” casualties (those with these symptoms). Our primary referral source would be the legal system that had prosecuted these community members for displaying illegal symptoms and then had ordered them to become asymptomatic by participating in these services.

• Using the substance use model for any other psychiatric disorder, we would find 98% of psychiatrically challenged clients entering services under duress via legal or administrative mandates. These referral sources expect lifelong symptom remission because it is legally/socially condoned and accepted behavior. The clinical expectations and outcomes are ultimately secondary to legal or administrative remedies when clients cannot maintain lifelong remission from a chronic and persistent disorder.

• Using the substance use model for any other psychiatric disorder, we would describe clients who did not comply with the delivery system expectations using terms such as “in denial, chronic liars, gamers, drug/medication seeking, they don’t care about anyone but themselves, they should know better, they will have to suffer, hit bottom, manipulators, they aren’t ready to get help, they are chasing their symptoms, they act like they have control, they use excuses and don’t take responsibility for their behavior, they don’t deserve to graduate from the program.”

• Using the substance use model for any other psychiatric disorder, we would presume that one-size-fits-all treatment (inpatient) is enough, without psychiatric medications, outpatient services and predominantly peer-led self-help groups for aftercare.

• Using the substance use model for any other psychiatric disorder, we would graduate (discharge) other psychiatrically challenged clients from inpatient treatment with no expectation that they would be linked directly to outpatient services and not just self-help groups as part of stepdown continued support for their serious psychiatric challenges.

• Using the substance use model for any other psychiatric disorder, we would deride and exclude from the delivery system those clients living with other psychiatric challenges using medication treatment (psychiatric/methadone/pain management medications), because they were not actually in recovery, as well as belittle the staff members who work in these settings because they were enabling and codependent and just peddling drugs.

• Using the substance use model for any other psychiatric disorder, we would not take into consideration that clients need assistance in getting stable housing, food and a job, and may need case management for many months or years after discharge to support their efforts to manage their challenges.

• Using the substance use model for any other psychiatric disorder, we would treat people from a different culture, gender, religion or sexual orientation and living with substance use challenges in the demeaning and belittling manner that they come to expect due to stigma, when entering treatment, in treatment, at discharge, or when they decompensate and return for help. We would continue to stigmatize them for living with these challenges.

Taking all of that into consideration, in using the substance use model for any other psychiatric disorder, I would have been violating my professional ethics and violating the law for refusing to provide services or providing an inadequate system of care and then inadequate care itself to a class of people simply for living with “illegal” symptoms, as I blamed them for their failures and stigmatized them for having a serious psychiatric or co-occurring disorder.

We can see the absurdity of this approach when applied to other disorders and the resulting challenges. Yet we continue to perpetuate these ideas as the norm. In the face of strong research and new models that provide care in rewarding ways, we continue not to treat these challenges in the way we do for any other psychiatric disorder.

I know we are attempting to do better for substance use and co-occurring disorder treatment services for complex patients/families. I know that paraprofessional and professional clinical staff can be and are being trained to engage clients/families with openness and acceptance while they are still symptomatic. I know that independent of the legal/administrative mandates, we can and do treat clients/families as normal people with challenges. They are encouraged to determine on their terms how to manage and live with these challenges. I know that these choices will have an impact on their lives, due to the legal/administrative mandates that brought most of them to treatment. I know we can and do walk with them through these consequences, treating them with dignity, respect, genuineness and high regard while supporting their self-determination. We are moving toward a better way of serving and defining recovery and wellness.

Here is hoping that we remain aware of the tension that is part of our growth and our efforts to be responsive, and that we remain vigilant on behalf of complex people/families living with challenges and the staffers who serve them.

Les C. Lucas, LMFT, is a behavioral health consultant currently supervising and training a rural behavioral health triage team that serves community members and families living with complex challenges. He also has a part-time private practice in Fresno, Calif.