Working in the field of AOD counseling can be a fascinating and rewarding career, but the reality is that when a person is experiencing a problem with alcohol, drugs or gambling, treatment is often the last thing on his or her mind.
Patients may present in crisis and engage for a couple of sessions, but for a large proportion of people, they may not even get as far as the first appointment. There will be too many barriers to accessing treatment including shame, stigma, getting there, getting time off work, paying for the session, as well as the age-old problem of ambivalence.
A person who is struggling with this type of an issue might swing between wanting to change, but also wanting to keep doing the behavior. There are reasons to change, but they are not always so apparent. Seasoned AOD counselors are aware that it is only when a person is truly ready to change, that they will turn up and actually start doing the work. Often change will be prompted by a series of losses, which eventually lead to a decision to do things differently.
Drug and alcohol treatment services, as well as gambling services, are notorious for struggling to show outcomes and efficacy for their treatments. It’s not because the services are bad, rather it is because the bulk of patients to this service are in the precontemplation stage – not actually ready to change, but being pushed by external forces to get treatment, whether that is the courts, a partner or their families.
There is no way a person will go through the pain and suffering of giving up an addictive substance, unless they are truly ready – until there are definitely more reasons to change than to stay the same.
There has been a lot of debate about how to improve these treatment services. Certainly, they are needed, with increasing numbers of people experiencing gambling, alcohol and drug issues. However, it is necessary to look at the reality, which is that traditional treatment services fall down because they simply don’t fit with their patients’ needs.
Working in community treatment services, I have seen clinicians engaging in incredible ways with clients, addressing past issues and allowing them to establish safe, effective and nurturing relationships in their lives.
However, this result is the exception rather than the rule. Most clinicians in this setting will describe half of their new patients failing to show up for their first appointment, or failing to return after their second or third appointment.
So, where does this leave us? To answer this question, we need to consider something about substance use or gambling. Yes, we know that genetics and challenging life events contribute to this issue, but we know that often it is isolation that keeps it going. A lot of the evidence that is currently emerging is that a supportive community is much more effective in instigating change than just one counselor, no matter how skilled this person is in building relationships and motivation.
Although quite divisive and with a religious orientation, AA has been lauded for its peer support approach, which utilizes a treatment-by-community model. Rather than being treated by counselors, it is other sufferers of the condition who offer support and insight.
Those who are further along their journey of recovery may take on leadership roles and mentor those who are new to the program. Many are turned off AA because of the commitment (you are expected to attend meetings on an ongoing basis), abstinence-only approach and the necessity for members to admit they are powerless against their problem (and thus put their fate in the hands of God).
It is an old-school approach, and one that has saved countless lives, but it is simply not for most of the population. AA epitomizes the ‘rock bottom’ idea and a lot of attendees are at the pointy end of the substance use scale – simply not where most people with an alcohol, drug or gambling issue are and never will be.
More recently, with new technology, new models of care that reflect this peer support approach are emerging in the AOD sector. In my work for an app that uses this supportive community with optional counseling, it is evident that something is changing.
In previous alcohol counseling roles, I became used to speaking to people who are struggling with alcohol use and who are well and truly ‘stuck.’ They have tried very hard to stop, over and over again, and counseling, while comforting, seems to sometimes reinforce this sense of a lack of agency.
The feeling of shame, hopelessness, self-loathing and utter helplessness is just about unbearable and contributes to that terrible cycle of alcohol use that perpetuates the stuck-ness and feeling that things will never change, so why bother?
Reading through the posts in this community, what is striking is that members are talking about the actions they have taken – celebrating their wins and reflecting on their mistakes.
It is almost as if they are having a therapeutic dialogue with themselves and their peers. It is overwhelmingly positive and reflective, almost the opposite of what would occur during a counseling session after a rough week.
In contrast to AA, the community is not abstinence only, although a large proportion of members are alcohol free (or AF, as they say). Something fascinating is happening when members engage with the community and post about their day – they are amongst friends, and that heavy burden of shame and self-loathing which often paralyzes and stagnates counseling, seems to have been replaced with a sincere desire to be honest, connect and learn.
People use the app like they use Facebook> It is something they jump onto in their down-time, on the train in the afternoon or on the couch after dinner. It is something where they chat, share stories, support each other and talk about what they want out of life.
It is the kind of talk that counselors try to elicit out of clients every session, but which it is so often impossible to do when they are so `stuck.’ They are rooted in their issues and sitting there in front of them talking about their failures is almost a confirmation that there is something terribly wrong with them.
The Wrong Way?
Removing the counselor and leaving members to be their own counselors and pitch in for others, seems to kick start that part of themselves that has been lying dormant – the healthy, determined part which is ready to make changes.
The implications are fascinating, particularly for someone who has made a career in the field of addictions counseling. Could it be that, all this time, we have been going about this the wrong way and rather than having a ‘well’ person counseling an ‘unwell’ person, we could put a lot of people with the same issue together and let them figure it out themselves?
Counseling, while a wonderful tool for revealing patterns and dynamics as well as address mental health issues, can also be inherently unequal and reinforce that assumption of badness and inferiority.
For substance use at least, peer support works because it allows us to sit in others’ shoes and see the things that we aren’t ready to see yet in ourselves. As a peer you don’t have to be the sick one – you can be a mentor, give advice, give commiseration or encouragement.
The most recent data for our app indicates that around 30% of members see a reduction in their alcohol use after a month, as well as improvement in their sleep and mental functioning. Interestingly, only around 7% of the community speaks to a health coach.
This data reinforces the idea that it is the community itself and the people within it, and its unique makeup and rules, that are somehow creating this change, not the people who supposedly have the answers.
Interestingly, when members were surveyed about what they wanted in a health coach, they were less concerned about qualifications and more interested in talking to someone who was non-judgmental, supportive and informed about motivation and change.
My sense is that, in the future, this model of treatment may bypass the existing services. There is the large portion of the population who we would describe as ‘dual diagnosis’ or who have a co-existing mental health issue as well as substance abuse. Perhaps this population would benefit from the one on one counseling that services offer, but with a focus on the mental health issue itself rather than the addiction and behavior.
A large percentage of members who use our app fall under the dual diagnosis condition and have still seen good results. The two aren’t mutually exclusive and it can be anticipated that when you cut back on your drinking, your mental health is also likely to improve.
Similarly, the more linked in a person is to a positive community, the better he or she tends to feel and the more resilient the individual is against episodes of physical and mental illness.
The community approach, so often used in rehabilitation units and hospitals, may prove to be a cost-effective and efficacious way to improve treatment services. We must begin collecting more data on the feasibility and drawbacks of apps that provide a supportive community, as well as understanding more about when counseling or psychological help is necessary.
It is clear that existing counseling services offer support within a ‘one size fits all’ approach and while often utilizing highly skilled clinicians, may not be utilizing the most valuable asset we have – each other.