Long-term recovery from a substance use disorder (SUD) is difficult to define. Some suggest that although recovery begins with the decision to change one’s use behavior, others suggest that it cannot commence until and unless one’s “change in use behavior” includes total abstinence. Still, others argue that one never recovers from a SUD and one remains in a perpetual state of “recovering,” although even with this, only if abstinence is maintained.
In other words, recovery would seem to mean different things to different people. What is imperative, however, at least for a behavioral health practitioner to remember is that how others define recovery is not the issue of primacy when working with someone having a SUD or mental health disorder (MHD). What matters is how that client understands recovery and therefore defines it and is motivated to pursue it. Supporting a client’s efforts to recover from a SUD or MHD necessitates acknowledging and working to support the client’s autonomy, that is, the client’s right to determine what he or she will or will not do; what he or she wants to accomplish with the practitioner’s help. Now if one’s client wants assistance using heroin without overdosing, this may be something the practitioner is unable or unwilling to help the client pursue. That said, this practitioner might refer the individual to a user room such as they have in the Netherlands or other jurisdictions outside the U.S.
Behavioral health practitioners need to avoid dogmatic definitions of recovery for their clients. Preconceived notions about recovery tend to result in inadvertently directing clients to pursue the practitioner’s view of recovery, which may or may not be what the client wants or needs. Practitioners that pursue their understanding of what constitutes recovery is problematic in that it violates a basic ethical principle of counseling – autonomy…more on this in a bit.
“Recovery” by its very nature implies change…movement from where one is to where one wants to be. It implies movement from a problem to a solution. The challenge for practitioners, however, is to help clients identify what the best solution may be for each individual client rather than be quick to impose a one-size-fits-all recovery objective and expect the client to follow.
Before recovery can begin, one must recognize the need for this change. We see this in the 1st step of A.A. or N.A.; we see this in the individual who seeks treatment to address a mental health disorder, and we see this whenever someone conducts a cost – benefit analysis in one’s life and realizes that the price paid for continuing to do what has always been done is greater than that associated with making a change. The point remains, however, what this change looks like is not something imposed on the client but rather something the practitioner helps a client explore.
Recovery is a simple process that is incredibly difficult to complete. Behavioral health practitioners can assist clients in considering questions designed to increase the likelihood that the pursuit of recovery becomes a desired option. The “specifics” of what the client wishes to change must be specific and operationally definable and include specific steps that “set one up” to succeed…many little steps accomplished one-at-a-time. Clients need to understand the personal reasons for making this change…for taking these many and gradual steps and to understand why it is important to do all this lest quickly becoming bored, overwhelmed, or frustrated and quit.
Although these questions are intended for clients to consider, I suggest that practitioners respond to them personally. For example, consider something you have decided to change: Why would you want to make this change? How might you go about making the change if you wished to increase the likelihood of success? What are several reasons why making the change is a good idea? How important is it that you accomplish this change? These questions are adapted from questions Miller suggests are important when employing Motivational Interviewing to help clients consider engage in “change talk.”
Ask ten people to define recovery and you will get at least a variety of answers. Those whose recovery from a SUD necessitates abstinence will include abstinence as a prerequisite of recovery…those whose recovery involves involvement with a mutual aid or self-help group will include involvement with such groups in their definition. Practitioners who define recovery as successfully completing treatment and aftercare plans will view this as a prerequisite of recovery…and blame the client if such is not realized. In short, recovery is what recovering people do.
There is an African adage that says, “When elephants fight, it is the grass that suffers.” Is abstinence required for SUD recovery? Is spontaneous recovery real? Can you be in SUD recovery if you are taking meds? Does medication-assisted treatment clear a path to recovery? Can one ever be truly recovered or is one simply in a perpetual state of recovering?
These are all very real questions, some of which are quite controversial. Although they are interesting to consider as they unfold at a professional conference, debating their usefulness with a client can quickly sabotage efforts to assist an individual with a SUD or MHD who is seeking treatment.
The American Counseling Association defines autonomy as the principle that addresses the concept of independence. The essence of this principle is allowing an individual the freedom of choice and action. It addresses the responsibility of the counselor to encourage clients, when appropriate, to make their own decisions and to act on their own values. Clients who are told they must do “whatever” if they wish to recover have had their autonomy hi-jacked. It can be argued that to define recovery for a client is to violate the ethical principle of autonomy or the right a client’s right to choose a course of action to pursue in treatment.
If recovery involves the movement from “problem” to “solution,” who should define what is a problem and what is its solution? If recovery is possible, then is it a process with a finite point denoting completion or a continual progression toward an ever-improving state of recovery?
How can you, as a practitioner, guide a client on this journey of recovery without imposing your understanding of what recovery is? Are you, as a practitioner, in a state of recovery from your preconceived ideas and notions regarding treatment and recovery? These are all important questions, and ones difficult to answer without having someone or ones with whom to discuss them.
It is when the person who happens to be a behavioral health practitioner connects with the person who happens to be his or her client, the “person connecting with another person” dynamic, that is the point when the magic happens in counseling. So, clients, when presented with the opportunity to consider all the options that are available to them, can choose their own course of action, this is when the path to recovery becomes obvious. Effective counselors can present their clients with probing questions designed to provoke objective thought about the pros and cons of each option being considered, but they will never direct a client to choose a particular option, directly or indirectly, especially if that option suggests a “one-size-fits-all” course of action.
Remember:
Control leads to compliance; autonomy leads to engagement.
― Daniel H. Pink
Unsolicited advice is the junk-mail of life.
-- Bernard Williams
What do you think?
