Wilson and Thorp (2008) cite three categories of the possible effects of substance abuse during pregnancy: (a) effects on the mother, (b) effects on the actual pregnancy and delivery, and (c) effects on the fetus, infant, and developing child. Medical complications are numerous and the actual effects depend on the substance ingested by the mother. Some notable effects on the child are fetal alcohol syndrome (FAS) characterized by mental retardation, facial deformations, and impaired growth is due to ETOH ingestion. Cocaine use during pregnancy has been associated with spontaneous abortion, and heroin use during pregnancy is associated with a 50% incidence rate of low-birth-weight and repertory depression in newborns. Mother’s being treated with OMT for heroin addiction will require elevated doses of methadone as the fetus grows due to the fetus’ use of methadone. After birth the child is given morphine to manage the symptoms of withdrawal syndrome.
Treatment for pregnant women involves care for both the mother and the fetus. Counselors working with this population need to be familiar with prenatal care and development. Motivational interviewing is often used to facilitate change in mother. Additionally pregnant women are often highly motivated to arrest their substance use. The opportunity exists to make progress in their recovery (Wilson & Thorp, 2008). CSAT TIP 2 offers information regarding legal and ethical obligations pertaining to treating pregnant women. Federal and state guidelines exist pertaining to communication with CPS, communication with medical providers, and confidentiality limitations. Too numerous to detail in this writing it is important that counselors are properly trained in this modality. More information is available at http://adaiclearinghouse.org/downloads/TIP-2-Pregnant-Substance-Using-Women-83.pdf.
Advocacy for clients is a competency required to be a counselor. Mental health counselors in particular function as advocates when a client who may be “marginally acculturated” requires assistance in dealing with oppression or discrimination. Counselors acting as advocates assist clients in overcoming institutional barriers the stand between their clients and their client’s goals. (Corey, Corey, & Callanan, 2007, p. 519). Corey, Corey and Callanan (2007) cite three different levels of advocacy required at the: (a) individual level with the development of underlying empowerment skills in the client; (b) community level with the consultation among “allies” to advance ongoing empowerment; and (c) the societal level with the increasing of public awareness to social injustices due to discrimination or other societal stigmas.
Advocacy for clients can bring to the surface deed seeded beliefs of counselors. If a counselor believes it really does take a village then he may be more inclined to offer advocacy even when it is really not required and the client is perfectly capable of handling the situation. On the other hand, if a client believes in the power of the individual and that life is never fair he might be more inclined to stay with client actualization in lieu of advocacy. These extremes may surface at the group level as well. A pastoral counselor may have a hard time advocating for LGBT issues where as a LGBT counselor may have a hard time advocating for the rights of a “skinhead.” I have not encountered any groups that I struggle with advocating for yet, but I am sure I will. Consultation and reflection are the only effective tools I have found to deal with issues as they come up.
Association for LGBT Issues in Counseling (ALGBTIC)
The Association for LGBT Issues in Counseling provides resources to “promote greater awareness and understanding of gay, lesbian, bisexual, and transgender (GLBT) issues among members of the counseling profession and related helping occupations.” Information and resources are provided specifically to assist counselors and other helpers develop competencies surrounding the treatment of LGBT individuals. The competencies are detailed according to 2009 CACREP standards and cover the following areas: (a) Human Growth and Development, (b) Social and Cultural Foundations, (c) Helping Relationships, (d) Group Work, (e) Professional Orientation and Ethical Practice, (f) Career and Lifestyle Development, (g) Assessment, and (h) Research and Program Evaluation. Additional information including surrounding multicultural issues and referral sources is also available.
Gay and Lesbian Medical Association
The Gay and Lesbian Medical Association provides information to patients and providers in order to “ensure equality in healthcare for lesbian, gay, bisexual and transgender (LGBT) individuals and healthcare providers.” The organization provide advocacy for the LGBT community concerning health care issues. There is a provider network available to members connecting the patient with LGBT competent providers in all health areas. There is a wealth of empirical data and other information specific to treatment of LGBT issues such as crystal meth and creating a welcoming environment. Finally there is information pertaining to students, continuing education, and their annual conference being held in Baltimore, September 10 – 14, 2014.
Parents, Families and Friends of Lesbians and Gays (PFLAG)
The Parents, Families, and Friends of Lesbians and Gays (PFLAG) is an organization designed to “celebrate diversity and envision a society that embraces everyone, including those of diverse sexual orientations and gender identities.” The organization provides education and resources that cultivate respect in all areas and in particular schools. Advocacy is put front and center with families and friends providing support for issues such as work place fairness, school bullying and discrimination, military, and general relationship recognition. Information on how to start a local chapter is also available as well as a directory of existing chapters nationwide.
The Pride Institute is committed to “providing lesbian, gay, bisexual, and transgender people a road to recovery through evidence-based substance abuse, sexual health, and mental health treatment.” Residential and partial hospitalization, with residency, programs are available for the treatment of substance use disorders, process addictions, and co-occurring psychological problems. Outpatient services are also available. The facility is located in Eden Prairie, MN with offices in Minneapolis. The site provides information specifically geared towards the LGBT community regarding self-assessment, family issues and health concerns. Finally, some empirical support is provided for the treatment modalities used however the site generally provides information specific to treatment at the institution.
Corey, G., Corey, M. S., & Callanan, P. (2007) Issues and ethics in helping professions (8th Ed.). Belmint, CA: Brooks/Cole.
Wilson, J. & Thorp, J. (2008). Substance use in pregnancy. Global Library on Women’s Medicine.
In nature there are neither rewards nor punishments; there are consequences. – Robert Green Ingersoll
Growing up in my family, as I did, there was a good deal of yelling about alcohol and drugs but not much in the way of advisement that I can remember. My father drank early and often. My response was to have my first beer at age 10. The school system educated me to the degree it could, I guess, but spent most of its energy I recall on enforcement and drug-sniffing dogs for locker searches. My response – on my senior trip to Washington, D.C. my friends and I loaded beer on the buses in coolers filled with ice. I was drunk by the time I got to the first monument. There was Nancy Regan’s infamous laugher, “Just say no,” and Nixon’s “war on drugs” was well on its way to being the miserable failure it is today. My response – by the time I entered college for the first time I was using, or had at least tried, alcohol, weed, acid, an assortment of pills, and cocaine. The more people tried to stop me, the more I stuck my middle finger up in the air. My friends were the same; it was what we did. There was nothing that discouraged our use. Sure there was the occasional slap on the wrist like cops dumping our beer out or a parent throwing our weed away, or did they smoke it, but nothing serious. That was all about to change.
By the time I was 25 my father had stopped drinking crediting Alcoholics Anonymous, and another family member had literally arrested his cocaine habit through the U. S. Navy’s brig in Quantico, the Maryland Department of Corrections, and later Narcotics Anonymous. However before either of them “got clean” I had severed my relationship with both. I continued to use drugs and alcohol in spite of the consequences I witnessed. For a good while my use allowed me to be functional but it eventually caught up to me. I will spare you the details, but suffice it to say there were plenty problems. I stopped only when my consequences were sufficient enough that I paid attention.
My actual views on drug use have not changed much since I was an adolescent or young adult. There is not much an adult who either drinks or does not drink, an education system that speaks one way and acts another, or a political system with fancy slogans or mean dogs can do to prevent an adolescent who believes he is invincible from participating in unhealthy behaviors; be it drugs or something else. It is only suffering the consequences of unhealthy behaviors that stop those same unhealthy behaviors. I have come to understand that it is the enabling of drug use, the prevention of meaningful consequences, that is the great perpetuator. It is not the high. Any heroin addict will tell you it is the fear of withdrawal or being sick – facing the consequences – that keeps the use going long after the high is no longer available. Allowing people to face the consequences of their actions, as Alcoholics Anonymous puts it facing their unmanageable life, worked when I was younger and it works now.
The first thing I say when speaking to the families of drug addicts is, “All enabling must stop now.” The consequences of the addict’s actions are what they are and the addict must understand and deal with, one way or another, those consequences. Treatment is not enabling, but three stays at a 5 star treatment facility with a spa and tennis courts might be. Maybe a stay at the Department of Corrections treatment center is in order. You get the point. I will treat people wherever they are in their process. I will use educational methods, motivational interviewing, and cognitive behavioral therapy to assist them in understanding their choices (educational), understanding the consequences of their choices so far (MI), and finding new ways of making choices (CBT). I will respect their choices and be there to support them in their choices. If their choice is to continue using, I will be there should they make it back. The only thing I will not do is to enable as that doesn’t work.
Sometimes our teachers in life show us what not to do.
Cookie Monster is my hero. His thoughts and emotions are in complete alignment with his singular goal – “More cookies!” One might say that Cookie Monster’s self-regulation muscle is nonexistent. But is it really?
Heatherton and Baumeister (1996) considered self-regulation failure to be an individual’s failure to engage in activities conducive to attaining his goals – “underregulation” – or and individual’s engagement in activities that are counterproductive to his goal – “misregulation” (p. 92). I am one of those currently going to graduate school fulltime and working fulltime, and I am getting tired. During the past month I have engaged in both underregulation and misregulation. I have purposefully chosen not to go to the gym knowing that running and working out is one of my primary sources of stress relief – underregulation. Additionally, I have fallen asleep on the couch and remained there all night resulting in a lack of quality rest knowing that I do not function well without quality sleep– misregulation. I have actually done both of these on more than one occasion this semester alone. That said, I have been going to school fulltime and working fulltime for the better part of three years. I am actually pretty good at managing my stress, and consistent with Heatherton and Baumeister’s view of self-regulation it is unlikely that I am going to forget how to self-regulate. However, if I am not careful it is very likely that I may choose not to self-regulate and engage in behaviors incongruent with my educational and licensure goals resulting in unintended consequences.
Now, back to Cookie Monster. Everything he does is for the purpose of eating more cookies. His self-regulation muscle is probably stronger than most as all of his actions are congruent with his goal – getting more and eating more cookies. It is others that put things in his way. Cookie Monster simply ignores the others and goes about the business of getting more cookies – stress free. It is amazing what we can learn form a fuzzy blue puppet.
Heatherton, T. F., & Baumeister, R. F. (1996). Self-regulation failure: Past, present, and future. Psychology Inquiry 7(1), 90-98.
As I have stated in prior posts I view life through a libertarian lens. I also struggle with the idea of God. One might think those two things combined might rule out the possibility of my integrating a 12-Step philosophy into my life. However in dealing with the God thing I have determined when tracing existence back to the initial spec of dust, independently of any 12-Step program, that I did not put it there. I am relatively sure you didn’t do it either. I am forced to admit that I have no idea how “it,” whatever “it” is got there. I just know I am not in control of such things. If someone else wants to call the one or thing in control God, who am I to argue. As for the 12-steps someone once told me after reading It Works: How and Why, the 12 steps and 12 traditions of Narcotics Anonymous, “[T]his isn’t a bad way to live, even if you are not an addict.” I agree. There is nothing about the 12-Step philosophy I could not integrate into my life. If I am wrong, I can promptly admit it. I am powerless over what you think of my writing style – I choose to believe you like it. If you want to know about how I live my life, I can tell you letting you decide what to do with the information. I can take responsibility for my role in my problems – always a tough one.
When it comes to the 12 steps and CBT, that can be a challenge. I work in an abstinence-based partial hospitalization setting where I conduct a number of psychoeducational groups. The client’s attend daily Alcoholics Anonymous meetings as part of treatment. One of the groups I conduct centers on External and Internal Locus of Control and one of the goals of this group is to assist client’s in gaining insight into their underlying belief system pertaining to control. In order to relate this to a 12-Step program I use the Serenity Prayer:
God grant me the serenity
To accept the things I cannot change
Courage to change the things I can and
The wisdom to know the difference
Clients work on gaining the insight into what they believe they can control and what they believe they cannot and correcting the distortions, which translates into – the wisdom to know the difference. Twelve-step programs are not for everyone but integrating them into recovery therapy will go along way to help the client gain insight and create new friends.
To argue against pharmacotherapy just does not seem right. After all I used varenicline, better known as Chantix, to help me stop smoking. It worked too, I guess. The drug absolutely helped, I think. It is very possible that I may not have been able to stop smoking without it or maybe I could have. The truth is I really don’t know. However, I do know there were risks associated with its use. There was the possibility of depression or even suicidal thoughts – I had neither. I did however have the most amazing Technicolor dreams. My point . . . there are always side effects.
So what are the side effects of other pharmacotherapies? There are the obvious side effects of the drugs. For example methadone hydrochloride, commonly used in the treatment of opioid use disorder, may cause constipation, drowsiness, and sexual dysfunction. Buprenorphine, also used in opioid management has similar side effects. Disulfiram, used in the treatment of alcohol use disorder, has been know to cause headaches, severe stomach problems, and impotence. There are also unintended consequences, non-physical side effects, of pharmacotherapy. Boosting, enhancing methadone with benzodiazepines, is a common practice at methadone clinics where drug testing is often infrequent. Buprenorphine, often prescribed out of a doctor’s office, is often sold to buy heroin. But, I suppose one could make the argument that the side effects of pharmacotherapies are better than the side effects of heroin and alcohol. I would agree with this line of reasoning.
What about the client’s mental health? There is a truckload of evidence indicating pharmacotherapy is effective in the treatment of substance use disorders. Pharmacotherapy gives the brain a chance to mend and return to the working state it was prior to the drug use. However, in the case of many addicts the brain is now functioning in a world that, for him anyway, is distorted, painful, and unsafe. The problems that existed before and during active addiction are still present and often worse. In order for client’s to fully recover they must learn to live in this newly found old world. In order to do this the client must change or at least learn to manage problem behaviors. Pharmacotherapy alone cannot do this. Pharmacotherapy must be accompanied by effective mental health treatment matched to the client’s needs so the client can learn and practice new more adaptive behaviors.
Pharmacotherapy is a valuable tool neither necessary nor sufficient to solve the problem of addiction.
In his May 21, 2005 commencement address This is Water delivered to Kenyon University, a liberal arts university in central Ohio, David Foster Wallace spoke of default settings and choice of consciousness. He posited the following:
[T]here is no experience you have had that you are not the absolute center of. The world as you experience it is there in front of YOU or behind YOU, to the left or right of YOU, on YOUR TV or YOUR monitor. And so on. Other people’s thoughts and feelings have to be communicated to you somehow, but your own are so immediate, urgent, real.
Please don’t worry that I’m getting ready to lecture you about compassion or other-directedness or all the so-called virtues. This is not a matter of virtue. It’s a matter of my choosing to do the work of somehow altering or getting free of my natural, hard-wired default setting which is to be deeply and literally self-centered and to see and interpret everything through this lens of self. People who can adjust their natural default setting this way are often described as being “well-adjusted”, which I suggest to you is not an accidental term. (Kelly, n.d.)
By choosing to be a counselor I have contracted to do the work to alter my natural default setting of only being able to see the world from where I stand. I have committed to be well adjusted. If you are reading this, so have you. But, what exactly is well adjusted?
If I am looking at my client through my default setting of self-centeredness I cannot help but separate me from him. After all that could never be me – I can see what the problem is. I can “fix” his problem. In order to be well adjusted I must be empathetic and see the world from his point of view – I must feel the problem. In order to do this I pack up my self-centeredness and take it to my therapist. My therapist never lets me forget that my problems are about me and, more importantly, I am not unique. I am the same. There can be no us versus them as there is only us. I may not be bipolar, but he may not be married with children. He may not have the stress of graduate school, but I don’t have the stress of being in rehab. I don’t have their problems and they don’t have mine, but we both have family dysfunction of some sort, a genetic predisposition to something, and cognitive distortions of some type – even if his is just being a Pittsburgh Steeler fan. Self-care helps me to be well adjusted, which allows me to be empathetic and see the world as he does. That is everything but that Steeler problem. There is no cure for that one.
Thanks for reading and as always – One day at a time.
Kelly, D. R. (Ed.). (n.d.). Transcription of the 2005 Kenyon Commencement Address – May 21, 2005 – written and delivered by David Foster Wallace. In Daniel Kelly’s Homepage. Retrieved June 26, 2014, from http://web.ics.purdue.edu/~drkelly/DFWKenyonAddress2005.pdf.
“All I need to do is to stop drinking and drugging.” Many addicted persons say these words upon entering treatment. If only they were true. It is often the case, especially when treatment is successful, that changes occur in the whole person. The whole person might contextually include characteristics that supported the maladaptive behaviors – arrogance, isolation, and denial – as well as hidden assets that could support more adaptive behaviors – empathy, optimism, and hope. The whole person might also include social systems that supported the addiction – enablers, dealers, and careers – as well as those who are capable, given the skills to support recovery – family, sober friends, or sponsor. Switching out these contextual characteristics takes a good deal of time and effort. Understanding that the whole person is affected – physically beaten, emotionally stunted, spiritually void, and socially isolated – allows for the treatment of the entire person allowing recovery to take hold. Because of this I believe we treat the whole person and all the internal and external systems surrounding that person, not by choice but because it is unavoidable – it is who they are.
Given my beliefs, I have a very high tolerance for addicted individuals. Don’t get me wrong sometimes they irritate me to no end, and I will not engage with them if they are intoxicated. They test my patience, dedication, and tolerance everyday. But I believe they are sick. I believe they have a brain disorder with behavioral symptoms. For me, to express a low tolerance for addicted persons is the same as expressing a low tolerance for persons with cancer – I could do it, but what’s the point? By understanding this, I am allowed to treat them with compassion and the respect every person deserves. Like the person who may not beat their cancer the addict may not beat their addiction – I am OK with that. Just like the cancer patient the addicted client can feel respect, hope, and empathy. Granted they may have peculiar and irritating ways of showing they feel it, but they can feel it nonetheless. Given enough time and skills they will find a more adaptive way of showing it. I believe there is a direct relationship between the amount of time needed to gain these skills and my attitude dealing with the addict. I am the model for the addict – if I show a high tolerance for him, he may, as he heals, learn to show a higher tolerance for life.