Addictions Anonymous, 33: Pitfalls In Finding Treatment
This article belongs to Addictions Anonymous column.
Problems confront addicts when they decide to seek mental health services. They can be serious problems, but they are not impossible. Here are a few of the big ones:
Biased recommendations. If a fellow addict recommends a certain path to recovery, be it self-help a group, psychotherapy, or grandpa's hangover remedy, he or she usually recommends what worked for them. As I've said, friends may assume their path is the only path that will work for everyone, and they will be reluctant to suggest things they are not familiar with. Also, if you ask a physician for a referral, he or she will probably recommend another physician such as a psychiatrist, and then you are far more likely to end up with a prescription for some kind of drug; so far, although certain medications may be helpful, there are no miracle drugs or magic bullets to cure addiction. A non-medical psychologist may recommend another psychologist, and then you might miss discovering an important and relevant medical problem. If you happen to see a marriage and family counselor, chances are very good your family is going to be dragged in for therapy because that's what these folks do.
Almost everyone you are likely to consult will hold an opinion that is biased in some way. Biased, of course, means that something is short of being completely rational. We must make our own choices, so it is best to ask more than one other person for suggestions; in fact, ask as many as you can. Also, weigh the costs, time commitment, and the level of trust you feel you can place in any potential therapist once you meet that person. A therapist who works in a multi-disciplinary practice that includes a social worker, a psychiatrist, a psychologist, and counselors is usually better able to use appropriate resources in helping you. In other words, find a professional group practice and avoid the fellow working out of his garage.
If you don't really like and admire a prospective therapist you should probably keep on shopping. Not that a good therapist has to agree with you and flatter you, but you will have to feel trust in the therapist. They may have to tell you things you don't want to hear, but compassion and kindness are important. If you succeed in manipulating a therapist, if you play word games to avoid real change, then addiction wins, you lose, and nothing changes. Play it straight and honest at all times.
Poor regulation. Although a therapist may have impressive certificates, licenses and degrees on the office wall, none of this is any kind of guarantee of effectiveness. Of course, you should read every word on these pieces of paper and be sure you know what they mean and how the therapist earned them. If the clinician holds a state license, you can call the licensing board to ask if there have been any complaints lodged against the therapist in the past. The degrees held should be from recognized colleges and universities. Beware of certification and certificates; they are often awarded by special interest, non-profit organizations. Some certificates are based only on short workshops, a relatively few hours of supervised experience and a review of a person's general qualifications, not on formal education. I worked my way through years and years of education, so naturally I'm biased in favor of formal academic training.
Don't be afraid to ask the big questions such as, "How many different addicts have you treated?" "How long have you been in practice?" "What is your success rate and how do you measure success?" The least hesitation or reluctance to answer, or vague answers, should make your B.S. detectors go into alert mode. Any good therapist is going to badger you with endless questions, so you might as well get a few in yourself before the grilling begins.
There have been few studies to prove that state licensing or certification result in superior results. Overall, however, if you know the clinician holds a valid state license in a relevant mental health field, it will help you avoid unqualified or fly-by-night charlatans. In general, advanced degrees suggest that the therapist had the patience and intelligence to attend college for a significant period. Be very careful if the potential therapist holds only a certificate of some sort and has little or no higher education. Such a person should be working under professional supervision.
Pride. Your own pride can get it the way. Some potential mental health consumers feel they are above the simple self-help groups that are readily available. Some addicts, egotistically, believe they are too complex or too advanced in their addiction to be helped by self-help groups. Others simply look down on group participation and see it as something for uneducated and simple-minded people. In fact, a simple mind may be the ticket to a healthier life, but that's a different story. Let's just say that most addicts are far too complex for their own good.
To be understood at the deepest emotional levels by a paid counselor with advanced training seems much more dramatic and interesting than a self-help group. However, unlike many products and services, mental health is very poorly regulated in terms of the consumers' interests. There is no requirement that clinicians post their success records. Most do not bother to inform the client of potential risks. Only the most serious of ethical violations ever come to the attention of licensing or certification boards. The fact that a particular therapist or treatment method has little proven success is seldom a cause for investigation. In fact, there is no requirement that treatment effectiveness be investigated or reported. Most professionals are ethical and honest, but it is still up to you to make the final selection.
If you buy a bad mattress, chances are you can return it for something better; if you buy bad or ineffective therapy, you're stuck, and you may not even know it. By the way, many people with health insurance seem to feel that they are getting free treatment if the insurance company pays. As they say, however, there is no such thing as a free lunch. Somebody pays for everything, and the more different diseases the insurance people have to pay for, you will end up with higher premiums in the future. Treatment for an addiction problem need not be expensive, and a good program might cost as much as a good used car.
I recall talking with a lady who admitted that she had lost more at the casino in one evening than the cost of the entire program she was considering, and yet she was irate when told the cost of treatment. Somehow, in the minds of some gamblers and other addicts, real money is much harder to spend on real services, and they prefer gambling money which they firmly believe can somehow be won back unlike real money that is gone for good once spent for anything mundane like rent, food or therapy. I think drug and alcohol people often show the same kind of thinking.
Fashion. Mental diagnoses wax and wane in popularity or fashion. Clinicians are just as subject to fads and fashions as anyone else. Architecture is a profession, for example, that shows how architects are affected by changing styles; look around any big city and admire how building styles have changed over the years. Architects of the mind, therapists, if you will, are always thinking up and trying out new tricks and fads. Sometimes these are even based on research evidence, but sadly, the evidence we have to work with is often incomplete.
As I write this, something called attention deficit/hyperactivity disorder (ADHD) is all the rage as a handy explanation of human problems. Thirty years ago, if you experienced mental or emotional problems, you might have been called a schizophrenic. Before that, people with problems were simply called neurotics. Depression of various degrees and types is also currently fashionable, possibly because certain drugs become popular from time to time. And whatever happened to the popular existential neurosis diagnosis? O.K., you've never heard of that, but it occupied the attention of the mental health field not too many years ago, and now it's a bit out of fashion.
In addition to fashionable diagnoses, different types of therapy also come and go leaving little impact. It seems like only yesterday that something called EST groups were meeting all over the country and making money for their operators. Do you remember Transactional Analysis, or electroshock treatments?
Human problems are pretty much the same year after year, but the labels and the professional smoke and mirrors change often and rather irrationally. As I write this, in the early years of the Twenty-first Century, something called Harm Reduction is making the rounds of therapy shops. This is not so much a new discovery as a new way of looking at the therapist's task. If abstinence is too much to ask or expect, perhaps we can reduce the damage done by addiction and by relapse if we are tolerant of the client's desire to go on using. Applied to the skateboard, we would say that if you insist on using a skateboard, then wear your helmet, elbow pads and kneepads. If a child often gets hurt using a skateboard, riding that board is just a bad idea. If you've been badly hurt by addiction, more use is just a bad idea no matter how passionately you want to get back in and win that lost battle.
Some therapists will insist that you not use your favorite addictive while in treatment, others won't even ask. Intense addictive activity is mind altering; psychotherapy is also supposed to change how you think. Can both of these go on at the same time? I think not. Let us never forget that any addiction can be hazardous to your physical, mental, financial and spiritual health. Addiction is really just a dumb idea no matter how compelling and attractive is seems to you just now, but you probably know that. In any case, as you well know if you are a heavy user, addiction is not about money. Maybe therapy could help you figure out what it's really about.
Research has recently discovered something called natural recovery. What this refers to is something that should have been obvious to all of us for years: many, many people get into trouble with alcohol, gambling or other addictions only to come to their senses and either stop altogether or moderate their use. We know little about such folk other than that they do exist in significant number. They would have to be called problem gamblers or problem drinkers since, in our ignorance, we cannot diagnose them as pathological or compulsive users. We just haven't had a chance to get to know very many of these critters, but they are out there.
This natural recovery, free of any professional mental health intervention, would be the ideal treatment: low cost, self-initiated, responsible, and often effective. Thousands upon thousands of people get over-involved in gambling, drug abuse, alcohol, and other addictive behaviors, and when the pain starts to build up, they simply decide to quit. Sadly, many thousands more cannot quit without some kind of help. By the time gamblers reach Gamblers Anonymous or professional treatment, they have sworn off gambling many times; natural recovery has not worked for them, as it will not work for many addicts.
When eventually you get to reading something like this document, you have probably tried to slow down or stop the addiction on your own and failed. But, if you have just decided to stop, why not try it? Just stop and don't go back. Find better, more constructive things to do, or spend the time with family. But, if you've been down that road and stumbled, read on and try something new.
If you choose the right help for an addiction problem, will you be analyzed objectively for your personal strengths and weakness by a practitioner broadly trained in all aspects of mental and physical health, or will you be caste into the mold of whatever biases and prejudices are currently rumbling around in your clinician's head? Will you be fitted into the most appropriate type and level of care, a type of therapy chosen from a broad array of possibilities, or will the clinician stamp you into a mold and expect you to fit his or her diagnosis and specialty? Will you ever, should such a referral seem most appropriate, be referred to a Twelve Step group or to some other inexpensive self-help group, or even be told that you do not need treatment? I wouldn't bet on any of it, not as long as your money or insurance hold out. Once you've passed through the therapist's door, the chances of getting an official diagnosis rise almost to a certainty.
Simple na´vetÚ. If you should happen to go to a clinician whose reaction to your problem is, "Oh, what an interesting problem. I've heard that some people can be addicted to X," my suggestion would be to leave at once. Find someone who works with X, it's becoming a real specialty these days. There is no substitute for experience. Seeing one addict a month doesn't get a therapist very far in terms of experience. You need someone who has been immersed and who has survived the onslaughts of daily contact with problem users. During the years of my own work with gamblers and other addicts, my best referrals came from self-help groups. If your therapist has never heard of The Twelve Steps, or is dimly aware that something called Alcoholics Anonymous is somewhere out there, look for a specialist if you are looking for help with an addiction problem. The ideal would be someone who was broadly trained in psychiatry, psychology, or social work before specializing in addictions.
If, on the other hand, you have achieved a significant time of abstinence from your addiction, and if you are still bothered by other disabling symptoms, you may wish to seek professional help for those problems rather than for addiction itself. If you had problems such as anxiety, depression or mood swings before you ever started using, they are likely to re-surface during abstinence, and they will make relapse more likely.
Therapists should be chosen with a specific problem and goal in mind and it is extremely important that the potential client be precise about what he or she hopes to gain in therapy. Just trying to get a spouse to stop nagging you is not a good therapy goal.
If you are using an addictive now, and if it is a major life problem, you should first spend some time going to a Twelve Step group. People there are more likely to know of clinicians who specialize in addiction problems and they can tell you their experiences. If, on the other hand, you are abstaining completely and are still having personality and emotional problems, a self-help group along with a more general and less specialized approach may be helpful, although it is best if your therapist remember that addiction has been a problem for you.
Finances. Mental health clinicians work for money, just like the rest of the world. They will often do some pro bono or charitable treatment, but for an addict who may have squandered thousands of dollars in the past, giving free treatment just doesn't seem like the right thing to do. In the
However, alcoholics with great insurance programs have been known to enter alcoholism treatment time after time just to get healthy again and prepare for the next bender. That kind of program helps no one, of course. Most problem gamblers in a free enterprise economy will be asked to pay out-of-pocket for services when they are provided. And it's not cheap. In the
The One-Size-Fits-All approach to psychotherapy. Unless you are referred for a very specific problem, beware of therapists who operate with one basic methodology. We have a hypnotherapist in town that does only hypnotherapy, and he makes claims for its effectiveness that are simply incorrect and are not based on research. Hypnosis is not very effective for addictions such food, smoking, gambling or alcoholism. In the hands of a general and well-experienced practitioner, someone who knows and uses many different techniques, it has occasional uses.
Some therapists offer other single method cures such as meditation, biofeedback, mega-vitamin therapy, massage, relaxation training, deep bowel cleansing, acupuncture, hypnosis and whatever else is making the rounds on talk shows. Sadly, there are no magic cures, there are no easy answers, but there are better science-based solutions than the gimmicks I've mentioned. A person who does only one trick, acupuncture, for example, should only be seen if one is referred by a more general and well trained professional. Always ask to see the research that substantiates wild claims, and remember that opinions and testimonials are not research. Some of my past clients were used car salesmen and, wow, did they have strong opinions about what car a customer should buy. It was usually the one with the highest mark-up or biggest commission.
Unfortunately, I have to include some evangelical preachers in with the One-Size-Fits-All group. Be particularly careful about religion-based treatment. There are many fine pastoral counselors working out of or with a church or temple. They are broadly trained and usually have at least a Masters degree, but in working with clients they make sure that their work fits whatever guidelines church dogma sets. For example, some pastoral counselors will not refer a client for abortion or encourage anyone to get an abortion. Some will reject any possibility of divorce even when one partner seeks it. People of faith will, of course, not want to violate their principles, but they can and do work with secular (non-pastoral) mental health clinicians; when they do, they should inform their therapists of their convictions. Any ethical clinician will respect those beliefs and work within any restrictions they impose.
If your church counselor tells you that gambling is a sin, not a mental illness, and if you believe such nonsense, then you are in trouble.
There are some born again faiths that even discourage mental health counseling altogether. You may be told, for example, that Jesus is the answer to all problems, or that Allah, the Muslim deity, demands complete obedience. Some of these faith-based counselors have no training beyond Bible school and are completely ignorant of the general health needs of their clients. They are always attempting to recruit new members to the church and they demand blind obedience to their dogma. There is no scientific basis for their work.
Especially annoying to some folk are members of self-help groups who found personal salvation in Jesus and now hold it their duty to preach religion as part of the Twelve Step program. Somehow, in their eyes, you will never be good enough; you will never really be recovering until and unless you join them in their evangelical faith. But, religion and spirituality can and do follow different and often very separate paths. Keep your eyes fixed on the real goal: a return to thoughtful spirituality, compassion, and fellowship with others. When religion takes choice out of your hands and subjects it to dogma or to religious authority then, I think, religion is a bad thing.
Shame and guilt. Maybe you do have a lot to be ashamed of, but seeking help for a serious problem is not one of those things. Your medical and therapy records must, of course, be held in the strictest confidence, and you might want to ask who will have access to your files and how they will be safeguarded. Your therapist will have to inform your insurance company about the diagnosis if you have health insurance, but there is no reason why your employer or others in your life need know. There are a few special cases such as when you have a parole officer or court appointed investigator following your progress; he or she would have to be told of the diagnosis.
If you are shopping for a therapist there are a few more general cautions to keep in mind. I use the word shopping to remind you that you are the customer. You certainly don't have to take the first therapist you meet, and you should interview several, even if that seems awkward.
When I use the word therapist it includes psychologists, psychiatrists, clinical social workers, nurse practitioners, counselors, etc. In short, the word means anyone who is offering treatment or therapy for an addiction problem in exchange for payment and who has the appropriate advanced degree.
Qualification: Avoid any therapist who resents being asked about his/her qualifications or, on the other hand, boasts and makes extravagant claims. An ethical therapist usually displays diplomas and certificates in a prominent office location where they can be inspected. Take time to study these. It is perfectly acceptable for a prospective client to ask about experience, specialties, and training. You will be better served by someone who treats addictive behavior frequently and has earned the qualifications necessary for doing this work.
The office: Is there, in fact, an office, and how efficient does it seem? In general, therapists who practice alone out of their homes should be looked at very carefully. Practice out of a home may mean that you can't contact the person easily, that billing may be inefficient, there may be not malpractice insurance, etc. A therapist who offers to come to your home may present similar problems. Unless it is a person you know and can trust, I suggest you look for a therapist in a group practice working out of a real office with clerical and professional backup.
Acceptance of self-help groups: Avoid a therapist who rejects the idea of self-help groups or knows nothing about them. Do not hesitate to ask for an opinion about self-help groups, but avoid getting into a debate. They have a right to their opinions just as you do. Some professionals ignore or even recommend against participation in self-help groups such as Alcoholics Anonymous. Keep in mind that those groups will be available to you long after your therapy is over. And they are free. There should be not sense of competition between the therapist and self-help since they usually work well in combination.
Quick fix, one tool therapists: There are endless gimmick salesmen out there offering herbal treatments, acupuncturist, age regression, magic touch, aroma therapy, etc. In general, avoid so-called New Age and alternative therapies. Also, chiropractors have little to offer addicts, in my opinion.
Excessive testing and interviewing: Walk away from the therapist who heaps psychological tests on you and then provides no qualified person to review the results with you. They are your test results, not theirs. Testing is not a bad thing when used as an adjunct to therapy, but this person may just be doing research, and if he or she is, they should be asking you for permission to include your information in their research. They should be asking you to sign an informed consent document. It's possible that the therapist is just being cautions or has a healthy distrust their own casual impressions. It is also possible that the therapist wants to get a complete profile in every case since, as often happens, there may be more than one addiction or emotional problem. When in doubt, ask about the purpose of all the assessments, interviews and tests. The answers should be clear and logical. If you have legal problems, the testing may be done to support your legal case in court.
Your informed consent: Get angry when you find yourself giving information that will be used in the therapist's research but for which you have not signed a document giving consent.
Privacy: Shun the therapist who will not discuss how and where your records will be kept or how your privacy will be protected. Abandon the therapist who discusses your treatment with your family or with others without your consent. Keep in mind, however, that in extreme situations the clinician may be legally bound to report information without your consent as in the case of an extremely suicidal person or one who voices a plan to hurt or harm others.
Therapist behavior: Start to worry if the therapist suggests any action with which your feel uncomfortable. This would include inappropriate touching, requests for social dates, a suggestion that you go out drinking together, bizarre forms of group therapy and so forth. You are always free to call the therapist's state licensing board or the organization that granted his/her certificates. You can also verify academic degrees by calling the registrar of the university or college attended.
Peer counselors: A counselor who has had an addiction similar to yours is a peer counselor in that respect. If your therapist is a member of a self-help group such as Alcoholics Anonymous, he or she should have advanced training and experience in the counseling field beyond having attended meetings and having a record of abstinence. Otherwise, taking money or even offering yourself as a therapist is a serious violation of Twelve Step traditions. A Gamblers Anonymous sponsor, for example, works within the guidelines provided by G.A., knows his or her personal limits, and never charges money to be a sponsor.
Religion: This bears repeating. Be cautious if your therapist makes frequent references to religion of any sort. Do not join any religious organization in the hope that it will somehow take the place of good psychotherapy. And do not donate money to any organization on the suggestion of your therapist unless you have investigated the organization very carefully and found that the money actually goes to whatever cause is being touted.
Sales pitches: Do not buy expensive extra services or products from a therapist. Outpatient treatment during which you live at home and attend individual or group sessions is to be preferred to inpatient hospitalization except in the most severe cases where there are suicidal ideas or other mental problems.
Other therapist faults: If your therapist talks all the time, relies only on cookbook mental exercises or gives endless advice, walk away. One the other hand, some therapists just listen and listen without ever coming up with an opinion of any sort; again, walk away. It would be better to find a friendly tree stump to talk to. Do be aware that many therapists reflect their own views in gentle questions designed to make you think about important matters. They are not there to direct your life or to be policemen. A good therapist helps you to see alternative ways of thinking and living, but never forces anything on you (except possibly that you abstain from addictives while in treatment).
Finally, always at the very beginning, ask how many cases similar to yours the therapist has treated. Ask how long the treatment is likely to take and how much it costs you or your insurance company. (With any national insurance program, the therapist may have no control over such costs.) Asking good questions is something we have to learn in life even if, in the past, we have been punished and insulted for asking. It is amazing how many people submit to radical surgery without ever asking for the slightest bit of information about what exactly the surgeon will be doing. Never do that with psychological therapies. Ask, ask and ask again until you understand or until you have to say, "Thanks for your time. I'll be thinking about what you said."