Further Reading

As a nonspecialist, I am worried about dealing with a drug abusing client — what are my prospects and liabilities?

Stanton:

I am a psychotherapist working with a 19yo male who's complaint is depression and mild paranoia. His mother is paying for the therapy although he is employed. He is currently abusing DXM (dextromethorphan) on a regular basis reaching "level 3 + 4 plateaus" multiple times weekly. I have only met with him 3 times. The presenting problems I see are dissociation, depression, flight of ideas (at times delusional) and mania, impairment in relationships, paranoia, and schizoid tendencies. My gut tells me to be cautious, and my beliefs remind me that therapy will not be productive while he is abusing. His family has a history (paternal side) of mental disorders including anti-social personality, schizophrenia, and manic-depression. His father murdered someone at age 19 during a fight and today tends toward "playful" violence, obviously inappropriate to me. I feel rather inadequate to deal with the issue of substance abuse, and am not an addictions counselor (although generally well versed in addictions, but missed this drug or the seriousness of it somehow). I am in conflict with knowledge of the abuse, his potential for a psychotic break, and confidentiality laws that provide for his continued cover-up of his addiction. Prior to this I was unfamiliar with DXM abuse, and the information available on the internet about this form of abuse alarms me given his family history and the beginnings of psychosis I am witnessing in him. I work alone when meeting with him, and am in a very isolated office building, and while he does not present himself as violent, I worry about a psychotic break from the DXM. Today in session he was obviously still affected from the previous day's trip. I would very much appreciate any ideas for an effective approach in working with him. In the past I would refer out when a primary presenting problem was substance abuse. This seems reasonable now, however, what I don't want to create is a situation where he falls through the cracks and ends up with permanent mental illness. He is also seeing a psychiatrist and taking Wellbutrin (311 mg/day). No doubt I would disclose the information about the DXM if a release of info were secured. Please forward you thoughts on how to proceed for the immediate future.

With many thanks,
Diana [...]


Dear Diana:

Well, you have many concerns. Fear of inadequacy towards a drug-using client, fear of violence from the client, questions of disclosure, confidentiality, treatment while using, etc.

  1. Dealing with Difficult Client

    Sometimes these cases come along. We've all had them, along with reactions like yours — unless the therapist is totally obtuse! My gut reactions are slightly opposed. I think ordinary (nonspecialist) therapists can handle cases involving drug abuse fine — especially when you consider that the alternatives will generally be some MA drug counselor or hospital program employing a 12-step template. Your client is also seeing a psychiatrist, which one might think provides some back-up. (How this might play out legally, I don't know.) Have you consulted with the shrink? Is he/she aware of the substance use? How does the prescription fit in with the illicit drug? One thing you may learn is that the psychiatrist is totally out to lunch. Don't feel bad that you missed the drug. You know now, and now is soon enough.

  2. Protect Yourself

    Your gut telling you to be cautious certainly shows your gut is in working order. Your fears of violence are especially to be considered. My worst fears of clients' acting out with me have never been realized. But with someone whose life is partly out of control with speed and whose family is violent, violence must be guarded against. Does he have problems controlling his aggression? Are you dealing with anger management? For your own safety, precautions (moving the case to a time when someone else will be in the vicinity, asking the mother to accompany her son and to wait outside, having a friend of yours come along, etc.) should be in order. Indeed, this situation gives you a chance to consider having other family members participate in the therapy — after all, your case description mentions both parents in the present tense.

  3. Treating While Person is Using—His Benefit

    You are worried about his current drug use. There are two fundamental issues — Will the person be better off if you refer them out and/or reveal their use?/What can happen to you in a worst case scenario? This site espouses a philosophy called harm reduction. This means that, no matter how much we wish it, many people, even (especially?) those who are abusing, will not cease using drugs. Shouldn't they be helped anyhow? As you note, many, many people fall through the cracks, because they won't quit using and because abstinence/12-step therapies are so insensitive in utilizing a one-size-fits all approach. The alternate approach that I use is to assess that the drug use becomes less harmful and pervasive, and that the person increasingly develops superior alternatives for coping. (Which is why, by the way, I wouldn't use the term addicted in treatment — because that suggests it is either/or, when in fact there are gradations of reliance on the substance, a gradient I am trying to move the person along.)

  4. Treating While Person is Using—Your Liability

    Directly parallel to this are issues of your own protection, not only from harm from the person, but from legal liability. Here again you need to protect yourself. The question of violation of confidentiality in this area is a tough one. I won't generally turn people in, because they often come to me instead of other (the vast majority of) therapists who would. The legal treshold is high — potential of imminent harm to self or others. You list a number of prepsychotic symptoms that could justify this standard. But you also describe an individual who is working and functioning. Again, have you consulted with the psychiatrist who is seeing your client, who would be generally more familiar with involuntary confinement? You should, of course, be keeping current records of your concerns, the precautions you take, your consultations with others, and so on. It doesn't often occur (it's never happened to me, but I have consulted with those for whom it has occurred), but records are safety nets in court. Does your insurance cover the potential problems that could erupt (consult your policy holder)?

  5. Treatment

    Ideally the question you need to ask, if you feel you are covered, is — "Do I have a realistic chance of helping this person, better than if I referred him out to standard drug abuse care providers?" In my own case, I believe the answer to that is nearly always yes. What does the person need? Can you orient him towards better functioning in dealing with himself and others? Can you teach him interpersonal and self-management skills? As I emphasize throughout my site, skills training is invaluable, as is client motivation. The drug use has its own dangers, but it also calls into question the person's wishes to be in therapy and to change his life (as does the fact his parents are paying). This impacts everything above. I might level with the person, who is coming to you as a legal adult:

    "Can I speak frankly with you? I am under some obligation to ensure that you don't harm yourself and others. Your drug use, or some varieties of it, seem to me to violate that. Are you able to cease using drugs while driving or in other situations involving danger to yourself and others? Because, otherwise, I will reluctantly have to stop treating you and to make other provisions. I think I can help you, but I can't sit here and allow you possibly to hurt people, which can affect my life as well. Do you understand? What can you tell me that will guarantee this doesn't happen?"

I hope this provides some framework from my experience that can help you deal with yours. You seem aware and sensitive; I always recommend that you don't overrely on DSM-IV categories and symptoms; they don't tell the truth. Or at least you should understand this person in a way that goes beyond what that book says.

Stanton


Stanton:

Thanks much for your imput regarding the 19yo client abusing DXM. You have given me some meaningful insight toward the direction and approach I take with him. After much thought this weekend, I am feeling more able to work with him and come up with a plan that is effective. Many, many thanks,

Diana [...]