Monday, October 14, 2013

Advice for Mental Health Clinicians

A clinician recently sent me this email:

Dr. Willenbring,

I read an article in the New York Times from early this year discussing Effective Addiction Treatment that in part highlighted your comments and Alltyr's mission to be a 21st century model for addictions treatment.

As a therapist in an outpatient practice not specializing in addictions treatment--but who nevertheless encounters co-morbidity with substance abuse on a pretty regular basis--it can be confusing to know how to approach the psychosocial aspects of treatment. I believe in a multimodal approach for chronic forms of addiction but there are tons of options out there for my part in that process:  motivational enhancement therapy, cognitive-behavioral, contingency management interventions/motivational incentives, the matrix model, 12-step, DBT, family behavior therapy, interpersonal neurobiology, etc. There is so much out there it's dizzying, and I feel overwhelmed. There are some that seem more indicated for alcohol, others that seem better for stimulants, another for opioids. I've worked for agencies that are sold on one particular treatment for every type of substance abuser, and others that turn their therapists loose to use whatever they think best.

I want to use the best, empirically validated approaches and everyone seems to have an opinion on what that is. Where would you recommend I start, particularly for treatment options?

Here's my reply:

Hi Jxxxx,

It is indeed a confusing landscape out there, both for non-specialist clinicians and for patients and families. 

A good place to start is with the ASAM textbook on treatment of addictive disorders. It's coming out with a new edition (or it has just come out). Also, the American Psychiatric Association textbook is pretty good as an overall summary of evidence-based practice.

On an individual clinician level though it can be confusing. Here are some thoughts:

First, there is no ONE RIGHT WAY to overcome addictions. There are many different pathways. Our job is to help each person find his or her own best way.

Second, a skilled clinician is usually effective no matter the specific technique, as long as the clinician is focused on the patient, not the technique or path. Focus on general skills, such as empathy, reflective listening, unconditional positive regard, and instilling hope. There is no evidence that a specific technique is more effective than another, except in specific circumstances. The relationship is more important.

Third, be patient oriented. Take them where they are. Find out what they want, help them clarify their goals and how to reach them. Help them learn skills to achieve their goals, while also gently helping them realize that the ideal goal (use without consequences) is out of reach.

Finally, be patient and let them teach you about their disorder and its nature. Recovery is a two-steps-forward, one-step backward process. Trying and failing is a necessary step for most people, and the important thing is to accept that, learn from each step back, and then look forward. Persistence is the key. 

A couple of other things.
Never use the words denial, codependency, or enabling. Don't threaten, cajole or berate. Don't share your own experience unless it is (very) clearly in the best interests of the patient (it usually isn't). 

Never question their motivation to get better. I've never met an addict who liked being addicted. They all want to feel better, but sometimes it takes awhile to figure what the way forward is. 

Accept that you can't help everyone. Why should we be able to universally help everyone with a complex human affliction? Be humble, but hopeful and available. Never blame the patient/client for the failure of our treatments, which are modestly effective at best. People die of this disease, and too often we can't stop it or know how to help them. People die from all sorts of illnesses. It's no different to die of a dysregulation in our brain than in our heart, immune system or pancreas. We need to get over ourselves a little bit. We don't need to blame the person with the disease in order to protect ourselves from our inability to stop it. 

And keep working, and trying, and stay hopeful and alive and open hearted. That does the most of all.

Thanks for writing,



  1. Dr. Willenbring,

    What a thoughtful and generous response. As the addictive treatment community becomes the "poster child" for what ails our entire sick care industrial complex, I love what you're offering in the way of an integrated, multidisciplinary approach.

    Returning to balance and wholeness cannot be a cookie cutter algorithm because we don't have a CLUE how to measure the whole. Recovering awareness about the wisdom of our self-regulating, self-healing mind-bodies IS a clue. Deep empathy and patient-centered care–another.

    Thanks for the great work you're doing in the world as the addiction treatment community becomes the entire community and we start practicing Health Care as the hopeful, alive and open hearted whole people we are.

    Dr. Herby Bell

  2. Brilliant. I have always found your approach to be compassionate towards the patient yet unemotional towards the treatment modality. In other words, you hold none of the sacred cows dear as much of the treatment field does, but rather you go where the evidence takes you.

    Your approach has helped inform the program I run and we certainly show the results which support the recommendations you make above.

    Keep up the great work, and keep sharing your knowledge.

  3. Well stated indeed. I have had the honor to observe your work and your style is a great reflection of your teaching.

    I strive to do the same, and find your direction both encouraging and affirming.

    Thanks for your leadership.

  4. sandy daignault, lcswOctober 19, 2013 at 6:21 PM

    very thoughtfully written- as a dual diagnosis therapist doing numerous groups per w eek in patient, I use all of the above mentioned therapies, but most importantly, the community knows our hospital has an unconditional place to come too if needed- the relationship throughout the years as they fight their addictions that gives hope is huge..

  5. Thank your for your words of wisdom and I have heard this time and time again, that empathic listening, instilling home, and unconditional positive regard is essential in counseling the suffering addict.

  6. What a lovely and thoughtful response to a good question! We have a practice of well-trained clinicians...who use MI, CBT, CM and DBT (that's alot of initials!). And at the end of the day, we know that the ability to establish an alliance, to work with a client where they are at when they are sitting across from you...with no emotional investment in how they what matters. And this takes alot of clincial skill, and training, and re-training....and supervision to maintain that balance. The outside culture with all it's opinions about addiction, denial, co-dependency and enabling...invades the work constantly. Thanks for pointing out that changing behavioral patterns (like substance use) is a process, that takes time and prolonged effort. And that is a windy, up and down road. I agree...I have never sat with a person dependent on substance who was happy to be in the position they were in. The heart-ache is more often immense.


Comments are welcome.