One thing I have encountered throughout my recovery and life as a therapist is the overwhelming effects of relapse on people’s lives, and the perseveration on relapse rates in the mental health and addiction field. In mental health, insurance agencies have gone so far as not reimbursing for treatment if a client readmits within 30 days on an inpatient psychiatric stay. Treatment centers treating addiction have continuous relapses after clients get out of the safe space of the “treatment bubble.” Many clients have told me how they have been stuck in the “treatment bubble” for years. In treatment, they do really well, maintain sobriety, go to meetings, do the work, then when they leave treatment, they relapse shortly after. And there is no good answer as to why. Is there ever really a good answer to why?
It is not because they stopped doing the work, it is not because they did not want recovery enough, it is not because it is addiction and that’s what happens, it is not because they stopped helping people, it is not because they are an alcoholic and there’s nothing we can do. It is so much more than that. As professionals, we can be doing more. Something we are doing is not working and we need to look at it in order to make a change. We cannot brush it off and call it spirituality because we choose to not take it personally. No, we must take it personally to allow it to impact us, to make us feel whatever we feel, to change us.
For one, I feel brokenhearted when one of my clients relapse. Not because I am taking responsibility for their recovery or their relapse, because I vowed to help people when I chose to become a therapist and work in this field. If my clients keep relapsing, clearly there is something I can be doing better. I am responsible for the work I do, for how I treat my clients, and how I change the work I do if clients symptoms are not improving. As a reminder, addiction is merely a symptom of something much bigger.
What are we missing? Clearly something we are doing is not working if clients do not maintain changes learned in treatment. What can we do? How can we be better?
Your Client is the Expert, Not You
Let us start with power and control. This is an elusive feeling that is difficult to explain with words because it is something we unconsciously feel. Sometimes people go years, decades, lifetimes, giving away their power and control and do not see it. I am going to attempt to explain this concept and how you can give more power and control to your clients.
When clients come into treatment, they have these deep beliefs they cannot do anything right, they have no value, they have typically destroyed their life beyond recognition, this life does not feel like theirs and they have no power and control in their lives. Their symptoms (mental health or addiction) have consumed their lives, leaving them feeling powerless, helpless, and hopeless. That is why they come to us, the “expert,” to help them fix their lives. The problem with this is many times we fall into the expert role, taking away the power from our clients. Especially if you are a professional in recovery yourself, you feel like you have figured it out, you know the way, you know how to get sober and live a life in recovery, and you are passionate to share your way with your clients. The problem is you only know what recovery looks like for you. There is no secret, there is no key ingredient, everyone’s path to recovery is different. This is especially harder if you were trained as an expert, a clinician, a doctor, a high up executive, or whatever your title is. It is important for you to play the expert at many times in your career, but when it comes to your clients, you are not the expert. Your client is.
When you humbly acknowledge, realistically, you have no idea what your client needs to do in order to stay sober or stay out of the hospital, you do not know what your client thinks or feels, what their deepest wounds are, or why they keep relapsing, then you can really be of service. Then you have an open, unbiased mind that will allow you to explore with your client. This also gives them the power and control, not you. By playing the expert, telling clients what they should be doing with their lives, then becoming frustrated when they “don’t listen” to your eloquent, expert advice, you are maintaining the power and control in the relationship, which is keeping your client stuck in the treatment bubble, rather than flourishing, understanding, and knowing they are the only one with the answers. Our job is to simply help them find the answers within.
How to Give Power in Treatment
As stated previously, people typically feel worthless when they first come to treatment. So, how can we help people to feel like they have value? Like they really are the ones in control of their own lives, no one else? One suggestion, and something I would do weekly, is a complaints and suggestions group. Ask clients for feedback. What do they like about treatment? What bothers them? Which staff are inflicting more pain than helping the clients? What can we do differently? What can we do better? What this does is demonstrate through actions, not words, how you care about your clients. How you are willing to ask them for feedback shows they have value. This is not something you can fake; you genuinely must care to ask this. Then you must be open, ready and willing to listen nondefensively. This is key. The natural reaction when you start getting attacked (which is likely to happen) is to defend yourself, defend your staff, defend your amazing treatment center, but those reactions are wrong. Once you start defending, you stop listening. The key here is to LISTEN. Accept their feedback as valuable ways to improve your treatment. This is an incredible process because clients who are used to stuffing down their feelings start to authentically express themselves. When you can feel proud of them for expressing themselves, no matter what it is, this will help you listen.
Commend them for speaking freely, for sharing what is on their heart, and for giving you powerful feedback. Clients tell you everything you need to know, and THEY are the ones with all the answers. When you take off your expert hat and allow them to wear it, they start to feel the power, and take back control over their lives. It is in these small steps that gives away your power and allows them to take the reins.
The second part of this group is to ask for suggestions. Once the venting session is done, and you feel like clients have gotten out their frustrations, or the anger is too intense, switch to suggestions and improvements. This is how I have redesigned clinical programming everywhere I have worked both inpatient mental health and addiction treatment centers, increased group participation, made clients excited to come to group and be a part of the recovery community, and continually, authentically, share themselves with me. Clients feel safe talking to me because they know I will not run or defend whatever they are going to tell me. My clients teach me everything I need to know. Clients have these creative ideas I never would have thought of myself, and never would have known if I did not ask for their feedback.
Sidebar, when clients tell me about me, they are always right. For how they perceive me cannot be debated. I get to choose how I use the information to become better. When I was a new therapist, I often had clients, sometimes psychotic, tell me how they could visibly see my big ego above my head. My natural reaction was, internal of course, “I don’t have an ego, they’re just psychotic, they don’t know what they’re talking about…” But the reality was, I did have a big ego, I was afraid of losing control on an inpatient psychiatric unit, as if I had any control to begin with! This is laughable now, but so many people make this same mistake, then take away all the power and control from their clients. This taught me to ask the clients what they wanted, give them options for group, put my agenda aside to listen to them and follow their lead on what they wanted to talk about and where they wanted to go with their treatment. When I followed the clients lead and gave up my own power and control, people started coming to group, they became engaged, they developed relationships, and we created this dynamic, inclusive recovery community on an inpatient psychiatric unit that was not seen previously. This completely transformed the entire feel of the unit and made people want to come to group… You know this is unheard of if you have ever worked inpatient psychiatry.
Not only does this group start to unconsciously give back power and control to your clients, it helps them to see how they are a valuable human being regardless of how many times they have relapsed or made mistakes. This helps clients to start to feel like they matter, like they have a voice, like expressing their thoughts and feelings helps to make positive changes in their world, and this change is transformational in so many ways in their lives.
Lastly, as staff, you must implement some of the program changes your clients suggest. Do not defend why their suggestions would not work, rather brainstorm to figure out how you can make some of their suggestions happen. For instance, the group really wanted to do a gender group, but we did not have the staff. So, this would have been a typical response, “we just don’t have the staff to make it happen,” making clients feel invalidated and feel like their suggestions really do not matter, unconsciously causing them to remain quiet and not speak their minds, the opposite of what we want for our clients. Instead, I came up with a way to split the group, gave one gender a writing assignment to work on for an hour while I took the other gender outside to do a process group. Then switched after an hour. Get creative! Regardless of staffing, you can figure out how to implement their suggestions. When I did this, implemented their suggestion the next day, the clients told me how much they could tell I listened, how they felt like I cared about them, and they felt like they mattered. This is life changing to a person who may have never felt this way, like they are good enough and they do matter. This is magic! This makes them feel powerful! And once a person starts to see they are the ones with the power and control in their lives, this builds the foundation for real recovery.
This group will also help you to prevent complaints, improve your Google reviews, keep a pulse on your staff, make program changes, and help your company grow. You can learn a lot about the negative energy in the community you need to address, staff that needs more training, boundary violations, etc. I would often process with my staff after this group to address staff concerns, let them know how they are making clients feel, and encourage them to vent their apparent frustrations they are taking out on clients. Your staff needs your support, too. Processing is helpful for everyone. I cannot tell you enough how valuable this group is. And if you do not have a group setting to practice this in, ask clients for their feedback regularly. It will make you better. And isn’t that what we are all trying to do?
“A leader is best when people barely know he exists, when his work is done, his aim is fulfilled, they will say: we did it ourselves.” – Lao Tzu
Improving the Treatment Bubble Effect
Another suggestion for treatment centers is to put an emphasis on follow-up care. This scenario happens too often to count where the client is engaged in treatment, does everything they are told to do and supposed to do, then transitions home, to sober living, back with family, etc. and they relapse shortly after. They quit taking medications, they do not go to follow-up appointments, they do not continue therapy, because in the treatment center we have not solidified follow-up care. Case managers and discharge planners are busy, they give a standard “follow-up care appointment,” then expect the client, who has grown reliant on the system, to take the initiative and go to their follow-up care once discharged, because that is what we told them to do.
We can be better. Something we do not do, which we should do, is begin to build a relationship with the follow-up care provider while the client is still in treatment. With telehealth and teletherapy on the rise, this can be done easily. In the last two weeks of a client’s treatment, the client should start their therapy appointments with an outside treatment provider. Maybe the current therapist can do a conference call with the follow-up provider to transition care, summarize what the client has done in treatment and where they are now, then allow the client to start working with their outpatient therapist for the last two weeks of treatment.
This will free up therapy hours for the therapists in the treatment center who probably have a caseload of clients in a higher level of care and require more therapy hours than the clients transitioning out of treatment. This will also allow clients to start to build relationships outside of the treatment center, breaking the unconscious bond of power and control to the treatment bubble. The client will be more likely to engage with their follow-up therapist while still in treatment and once the bond starts to build, will be more likely to continue follow-up care. Even if it is only for one month while they transition home. This is what is missing from our current treatment model.
I hope you found this article helpful. I would love to hear your suggestions and feedback on how we can be better. How can follow-up, outpatient therapists be better at supporting treatment centers? How can we work cohesively together? Would it be helpful to integrate follow-up therapists into your treatment? Maybe run a group once a week on the importance of follow-up care? Tell me how we can help you so we can work together as we all have the same goal in mind: recovery for our clients.
