There are a variety of ways in which to organize services in chemical dependency treatment programs. Services may be organized around the "drug of abuse," as is the case in many methadone clinics. Or they may be organized around the needs of the program. A residential treatment program, for example, may be organized around maintaining a clean and sober living environment; a program specializing in treating criminal offenders may be organized around urine monitoring or reporting requirements.
The ways in which services are organized may depend upon external factors such as funding, or upon internal design preferences. But the method used is often determined by the programs bias about where the locus or successful recovery resides. Does successful recovery depend upon living in a safe and sober environment? Does it depend upon another drug, used as replacement therapy? Does it depend upon the cultivation of a relationship with a therapist or counselor, or upon effective and comprehensive case management services? Does it depend upon the clients fear of the consequences of relapse? Does it depend upon education or relapse prevention services?
All of the factors mentioned above can have an important role in chemical dependency treatment. This paper examines some of the dynamics of client-centered treatment, whose premise is that the ultimate locus of successful recovery lies within the client themselves.
The "client-centered" concept was introduced in the field of psychotherapy by Carl Rogers in 1951. It was part of a revolutionary movement to get the Freudian therapist out from behind the desk, and to get the patient up from the couch in order to assume a measure of responsibility for the work of therapy. Rogers developed a style of therapy that was characterized by active listening, accurate empathy, genuineness, and spontaneity. But beneath the process was the important philosophical belief that the client had the inherent capacity to move toward healing. The agenda in the therapeutic process was the clients, not the therapists. There was unspoken faith that the clients agenda was immanently valid. The therapists role was to provide a safe container in which to cultivate and follow that agenda rather than to impose his or her own. In this model of client-centered therapy, all of the therapists interventions are organized around the inherent faith in the clients ability and willingness to move toward healing.
12-Step programs are "client-centered." All of the activities and "services" in the 12-Step culture are organized around the individual members recovery, and around certain traditions that assure the perpetuation of that emphasis. The locus of recovery, according to the 12-Step philosophy, is in the recoverer. The meetings and steps are designed to support the movement of the individual toward recovery, but the essential work belongs to the person, not to the group or the organization. In the words of a common 12-Step cliché, "Its an inside job."
Chinese medicine, and many other traditional healing practices, similarly assume that healing is not the province of the practitioner but of the patient. The body is viewed as a homeostatic (self-regulating) organism whose agenda is always balance. Disease is the result of imbalance, and the practitioners role is to assist and support the body in its agenda to regain balance.
Chemical dependency has two parts: the chemical, and the dependency. Both need to be treated if successful recovery is to be achieved. The chemical to which the client is addicted has caused neuro-adaptations in the brain that produce a cycle of cravings, anxiety, and depression. Untreated, these symptoms forebode relapse. The dependency aspect, in addition to having these neuro-physiological manifestations, is characterized by an emotional and psychological imbalance which must also be addressed. Chemically dependent persons who achieve abstinence from the chemical of choice frequently "switch dependencies" to other substances or to activities. They are also prone to becoming dependent upon the treatment program itself, or upon the modalities that are provided, or upon relationships with counselors or therapists in the program, or upon 12-Step or other support groups. There are dependency factors, inotherwords, which lie beneath the chemical addiction.
Client-centered chemical dependency treatment, in organizing its services around the clients recovery agenda, seeks to minimize the opportunities for the client to shift his or her dependency to the program or to any of its elements. The decisions that the program makes about what interventions to use and how to deliver them proceed from the two related assumptions: (1) the client wants to heal and desires recovery, and (2) the ultimate source of that recovery lies within the client.
Chemical dependency clients present a basic paradox in this regard. On the exterior, they commonly display signs of resistance, fear, anger, denial, and projection. The client-centered program assumes that there is another "client within" who desires health and recovery and balance if they could only figure out how to do it. The client-centered program realizes that most clients will be seeking wellness from outside in the form of drugs or some other "fix." The client will, in the words of AA, be looking for "an easier, softer way." Physically and unconsciously, however, the agenda of the client is recovery. They crave balance. They wish to put their affairs in order and get on with the business of their lives. They understand that the chemicals to which they are addicted are barriers to that goal. The client-centered program endorses, validates, honors, and supports this agenda, and organizes its services to that end.
The Three Goals of Treatment
There are three essential goals of all chemical dependency treatment. The first is client attraction. What does the program do to attract clients? This is generally a function of program outreach, promotion, and networking. But often, clients have choices about which program to select, so a programs reputation is also important. The second essential goal is client engagement. Once attracted, what is the programs capacity to engage the client in a process that is meaningful for them and which engenders hope that they may have a chance to recover? The third essential aspect is retention. Client retention is the central, necessary, and overarching goal of all substance abuse and chemical dependency treatment. Stated simply, if the treatment program can retain clients in treatment long enough for something significant to happen for them, then the client has a chance of achieving and maintaining rehabilitation; if the program cannot, the clients chances of achieving and maintaining sobriety are slight.
We will discuss all three of these elements from a client-centered treatment perspective. We will also be developing the argument that an acupuncture program component, properly organized, provides a unique opportunity for enhancing the client-centered posture of the program.
Client Attraction and Engagement
Imagine a client at the first moment of treatment entry. They walk through the door of the treatment program and are greeted. Community outreach and networking have been successful. Someone has walked through the door! They say, "I need to sign up," or "I was told to come here," or something similar.
The first person to greet them has an enormous responsibility. First impressions are always important, but the first impression here has additional significance. The clients first reaction to the program will shade their treatment experience and their attitude toward the services that are offered. They will either be attracted to this particular milieu, or they will not.
It will be helpful to look at this initial interaction in some depth. First, the person who is greeting the new client may be a counselor, nurse, administrator, or receptionist. The client will not know what the persons program role is. From the clients perspective, the person is simply a Program Official. They are someone in authority, a representative of what goes on in this place.
The greeter, regardless of their role, may safely make a few assumptions. First, it may be assumed that the person who is standing in front of them is an alcoholic and/or a drug addict. The person probably did not arrive at the treatment program by accident. Further, it may be assumed that some momentous event has just occurred in the persons life. Some consequence of their alcoholism or addiction have forced them to make a choice to cross this threshold. Perhaps their spouse threatened to leave them, or their employer threatened to fire them, or they were arrested, or they violated parole or probation, or experienced an overdose or other medical emergency. In the parlance of AA, they have hit a "bottom," and the bottom was significant enough to bring them to the treatment program.
One can additionally assume that they don't want to be there. The potential client can likely think of many places they would rather be than at the door of an alcohol or drug treatment program. They are stigmatized by their illness, ashamed of the consequences that have occurred, angry, and frightened. They have experienced a crisis of control in their lives. Since a primary human psychological defense is projection, it is also reasonable to assume that the shame, anger, and fear the client feels are being projected on the Program Official. The Program Official, the client will presume, is standing in judgment of them as a human being.
The most important fact to be aware of in determining our response to this new client is that the person has chosen to cross that threshold. Many programs labor under the myth of the mandated client. The client whose arrival is the result of a criminal justice or equivalent referral is also tempted to subscribe to this myth. They feel as though they were required to come to treatment. The reality, however, is that they made a choice. There was an alternative. The alternative may have been severe, such as incarceration, losing a mate or job, losing custody of a child, or even, in the case of medical consequences, death. But nonetheless, that alternative was not chosen, and the person decided instead to attempt treatment.
To realize the significance of this fact, it will be helpful to understand the precise role of denial in addiction and recovery. Denial is frequently identified as a premier symptom of alcoholism and drug addiction. The denial associated with these diseases, which arises in part from the cultural stigma with which they are associated, is most often not the denial of alcohol or drug use per se, but instead a denial of the consequences of that use. In the inverse, a clients acknowledgment that problems they have encountered are a direct result of their drinking or using is the first, best sign of recovery. Ownership of the illness and its consequences provide the cornerstone of recovery. The primary purpose of the "drunkalogue" in the 12-Step culture is affirming the ownership of the disease and its consequences.
The new client standing at the door is standing in acceptance of the consequences of their disease. Their presence is their testimony. They were willing to come to the program. That willingness presents a premier intervention opportunity. It is an opportunity that may disappear during the intake process, when the client will likely rationalize the consequence, and their denial will become reactivated.
The client cannot, however, rationalize the fact that they are presently standing at the entry to treatment.
So, the client has made a choice to present themselves for treatment. The Program Official also has significant choices. When the client makes their introductory remark, "I need to sign up," or "I was told to come here," the greeter can take one of three basic tacts: (1) they can greet the client in the context of the consequences that brought them there; (2) they can respond in the context of the disease from which the consequences resulted, or (3) they can respond in the context of the recovery that is being sought (remember our fundamental client-centered assumption that the client wants to heal and desires recovery).
The first tact, to respond to the consequences, is tempting:
"I was told to come here."
"Why?" or, "What happened?" or, "Whats going on?" or, "Who told you to come?"
This is a natural and human response. But in this situation, in this moment, it is a codependent response. It invites rationalization; it invites reactivation of the denial of the consequence.
Any variation of the question "What happened" is invasive as well. To expect an honest response to the question would infer that trust has been established, and at this point, it has not. So, the question invites fabrication. Remember our assumption that the client is projecting his or her fear on the greeter. The client presumes judgment on the part of the greeter, and will want to be thought well of. They are likely to say whatever they think is necessary to win some approval. The danger is that the clients very first verbal exchange with the treatment program will be characterized by deception. That produces guilt. Even if the client is ultimately successful in the program, the greeter will have become another amend to make!
So, responding in the context of the consequences has a cost at this stage, and it has no benefit from a recovery perspective.
Responding in the context of the disease is also tempting. It is an understandable clinical response to initiate the assessment immediately.
"What drugs have you been taking? How long have you taken them? In what combination? Is there a history of alcoholism in your family?"
Assessment and diagnosis are problematic in the early stages of recovery. The client is very likely to be toxic, and may be unable to provide accurate information. Or, there may be attending mental illness that exacerbates the diagnosis in that its symptoms resemble those of drug use or withdrawal. And, in any event, the diagnostic response also invites fabrication. Good diagnosis requires trust and honesty. The client needs to feel safe to disclose personal history. That environment has not yet been established.
People experienced in the treatment field will recognize the client entrance scenario we are discussing as precarious. Many clients come to treatment for a single visit and dont return. Many others fail to remain even for the first thirty days. We are, as we stand in the doorway or foyer with the client, still in the attraction phase, and the goal is engagement in a recovery process. In the client-centered program, inotherwords, whatever response the greeter makes needs to be meaningful for the client at a level which engenders hope that they may have a chance to recover. It must endorse, validate, honor, and support the recovery agenda of the client, which is to say the "client within" who made the conscious choice to come to the program.
This is an challenging proposition for the greeter. How can that be accomplished in this earliest encounter? The task may be initiated, of course, with the single word, "Welcome." There is a subset of the population of individuals seeking treatment for whom an vigorous welcome will be sufficient to launch them in their recovery. At the stage of greeting the new client at the door, the greeter of course has no idea whether this individual is a member of that subset or not, so a hearty welcome is appropriate, just in case! The 12-Step culture is especially good at welcoming and honoring the newcomer. They have welcoming rituals that provide psychological space for the newcomer to establish himself or herself in the culture of healing.
But this is not a 12-Step meeting; it is a treatment program. What intervention can the greeter perform beyond the welcome? Are meaningful, supportive, initiatory rituals possible?
As we have mentioned, acupuncture provides the chemical dependency treatment program with a unique opportunity to organize services and interventions around the clients recovery. While the physical benefits of acupuncture include diminishing the symptoms of acute and post-acute withdrawal, the manner in which the acupuncture clinic is organized within the program presents the additional benefit of allowing the program to be client centered in several important ways. This begins with client entry, because a program that has an acupuncture component will generally be open for initial intakes during the time that the acupuncture treatment is being offered.
In brief, the acupuncture service is provided and organized as follows:
To return to our scenario of our client at the door, the availability of acupuncture makes our greeters task simple and easily manageable. Their initial response to the client may sound something like this:
"Welcome. Im (Carol). Come on over here and lets get started. Have you ever had acupuncture before?"
The question, "Have you ever had acupuncture before?" is not especially relevant, but it is a safely benign question in that it matters little whether the client responds with a fabrication, since there is nothing invested in the question.
In asking the client to sign in, another opportunity to make a choice is presented. Other clients will be sitting comfortably in chairs in the clinic receiving treatment. The greeter need not explain that they are receiving acupuncture. The client will perceive what is happening.
"These are the needles. These are disposable. No one else has used them before. You open the packet like this. See, they are very tiny, almost like filament wire. The acupuncturist puts them a tiny ways inside the ear. You prep your ears with an alcohol pad like this (demonstrates) so you wont get infection. Fill this out and have a seat and Ill get you a cup of tea and the acupuncturist will be right with you."
This is a client-centered treatment entry. Everything that has been done has been in support of engaging the client as quickly as possible in a meaningful recovery process. There has been nothing invasive or intrusive. The client has not had an opportunity to rationalize his or her presence, or to move into denial and resistance. He or she has been given a small succession of simple, extra choices to "buy in" to a recovery process.
From a conventional treatment perspective, there may be several concerns with this approach. For example, there has been no diagnosis. We dont know if the client is "mandated" or not, and the program may have special reporting requirements. How are we going to bill for the session if we didnt do an intake?
All of these are legitimate concerns. However, they all represent the administrative or clinical agenda of the program, not the recovery agenda of the client. At the critical initiatory moment we are describing, the recovery agenda of the client should be the sole concern. Nonetheless, lets consider each of these concerns.
Diagnosis: An advantage of the acupuncture protocol we describe is that it is generic. The same five needle points are used regardless of the clients symptoms. Clients will benefit from the basic protocol regardless of their disease or recovery phase, and regardless of the specific drug or drugs they have been taking, and of how recently or frequently they have been taking them. There will be ample time for clinical diagnosis once the client has stabilized. Virtually all funding authorities allow thirty days for the development of a treatment plan. Acupuncture allows the program to take this time to successfully engage the client and establish trust before beginning the invasive process of assessment and diagnosis. The more the client has stabilized and detoxified, and the more trust the program has engendered, the more accurate the diagnosis will be.
Reporting requirements: There will be time after the client gets their first treatment to respond to any need to report the clients visit to anyone the client feels needs to know about the visit or about the status of having enrolled in the program. The client-centered program should not discriminate on the basis of the particular "bottom" that brought the client to treatment. If the client was referred by a legal authority, the treatment program wants to insure that it is not perceived as an extension of that legal authority. That legal authority represents the consequences of the clients illness; the program represents the tools and resources by which the client may recover from the illness. The clients relationship with the legal authority or referring party is their own. The client-centered program should let the client know that it will be happy to report the clients attendance to anyone to whom the client expressly requests that information be given. The client should be told in the intake process following their first treatment that their attendance is protected under very strict federal confidentiality requirements, and that if they wish the program to report their program visits to anyone, they have the right to waive that confidentiality in writing. Programs need to take care that they do not form enmeshed and codependent relationships with referring agencies in their community. All communications with those agencies need to be formalized and specific. Waivers of confidentiality need to be very specific as to what kinds of information will be reported. The program needs to educate mandating legal agencies that client retention is the key to successful recovery. Since the disease of addiction is characterized by relapse, and since the outpatient acupuncture program can be relapse tolerant, mandating agencies should be encouraged to accept daily attendance and compliance with the clients treatment plan as a legitimate basis for assuming that the referral was successful.
Intake: There are many barriers to treatment that are outside of the programs domain and jurisdiction. These include physical barriers, such as geography, transportation, and child care, and psycho-cultural barriers such as stigma, denial, and family or relationship systems that do not support the clients going to treatment. But there are also programmatic barriers to recovery. A programmatic barrier is anything the client needs to do at the treatment program before something meaningful and relevant for them happens. The program needs to assure that its intake requirements do not form a barrier to successfully engaging the client in the recovery process. The cost effectiveness of acupuncture allows the program to develop the policy that "The first treatment is free." Any intake that the program funding requires, or any discussion of fees, should follow the initial treatment.
Not only should the program avoid visiting these issues prior to engaging the client, but neither should it allow the client to "change the subject" by themselves visiting these issues prematurely. If, in the course of initiating the client to their first acupuncture treatment, the client attempts to move to non-recovery issues, the program official may respond appropriately. Following are some examples of how to keep the initiatory phase recovery centered:
"The court said I had to come."
"Well, youre welcome here. Have you ever had acupuncture before?"
"You need to tell my boss I came here."
"No problem. Well take care of that. Have you ever had acupuncture before?"
"I overdosed yesterday and just got out of the hospital this morning."
"Im really glad youre here. Have you ever had acupuncture before?"
"How much will this cost?"
"Well talk about all our services after we get you started. The first treatment is free. Have you ever had acupuncture before?"
"You wont tell my parole officer Im here, will you?"
"This is confidential. We cant tell anyone youre here unless you tell us to in writing. Have you ever had acupuncture before?"
Some clients will naturally resists acupuncture. Fear of needles is natural, and should be honored. It is best in these cases to offer the client a cup of tea and invite them to sit in the clinic where the acupuncture is occurring. This gives them an opportunity to watch others being treated and hence to allay their fears. Other clients will often encourage them to try it, or the acupuncturist may offer an "experimental" treatment of just one needle. If the client still declines, there will be benefit from simply sitting quietly in the clinic among those being treated for a half hour or so. Then an intake can be initiated.
The vast majority of clients will assent to the treatment. In most clinics, clients remove their own needles after treatment at a mirror. For the first treatment, however, the greeter or clinic monitor will approach the new client after forty-five minutes or so and instruct them on safety issues in de-needling. The formal intake, determined by the needs of the clinic, can then commence, and any questions the client has can be answered.
In this initial, "attraction" phase, our new clients primary identification with the program has been not with an individual but with a therapeutic process. If they return tomorrow, and the person who first greeted them happens not to be there, or even if there is another acupuncturist on duty, the client will still have a familiar and meaningful activity in which to engage.
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