Establishing Goals for Substance Abuse Treatment

Individuals who verbalize a commitment to abstaining from substance use or who enter therapy for drugs or alcohol, may not always be committed to the same goals for therapy as significant others who want him\her in treatment. I have worked in the chemical dependency field for over 25 years and believe it is important to understand someone’s motivation level when addressing this issue. A person may believe they could control or manage their drinking. Family members/significant others could be under the impression that goal is not realistic. Or a person may not believe their use is a problem and are entering treatment to appease others. This presents a conflict in treatment goals between client (person entering treatment) and others.

A therapist’s role is to help the client clarify goals in treatment. It is important to have mutually understood goals. If, as a therapist, I am presenting tools more consistent with someone who has a goal of complete abstinence, and this individual is not committed to stopping use all together, therapy will not be successful. The first step in the therapeutic process is endeavoring to be on the same page with the client. A helpful tool I use is the motivational wheel.

Once goals are established, we come up with tasks that will help meet these goals. If a person uses substances when his/her goals are abstinence we go over the motivational wheel again. We establish if the use was: a lapse (goal was abstinence but had a slip) or decision to use (goal was not to stop and decided to use). If it is determined to be a lapse, we examine goals and determine what areas may need further focus. Lapses are not uncommon in recovery and may actually help develop focus and commitment to stopping use. If the client made a decision to use, I will explore what may have changed from the initially stated goals.

Recovery is not a event, but a journey. Each person may carve their own individual
path. It may entail some slips or challenges along the way. For some it may take longer to reach this goal than others. What is essential in therapy is that goals in treatment are agreed upon, realistic, clear, and obtainable. If a person is not committed to stopping all together, my role will be to establish safe guidelines in exploring the costs to use and impact on one’s life.

Adolescent Anger

During adolescents, individuals are struggling with many developmental, social, emotional, and physical challenges. Peer relations, body image, hormonal changes, sense of identity, and independence issues are to name a few. Most adolescents are able to work through this time with very little difficulties. Others may have a more difficult time negotiating their way through this time. Youths are not always directly expressive of their feelings, trust an adult enough to confide in them, or be able to articulate their emotions themselves as to what is going on.

The emotions this age group is addressing may come out more in their behavior rather than through expressing them. A youth may not verbalize depressed feelings but act depressed. External events(victim of bullying, breakups in relationship) could also be a factor in this behavior. Often, the way they express their emotion is by anger. Anger may not be intentional but more of an expression of them struggling with an emotion or event. An adult’s job is to decipher behavior and help youths manage and express their feelings in appropriate ways.

The first goal is to determine if there is a benefit to their anger. For example, a youth who gets angry every time a parent requests them to do some chores or asks where they are going, may be shaping their parents behavior into not asking these questions for fear of an angry response. The parent may back off for fear of an outburst.

Even if the anger is not serving a function of avoiding accountability for the youth, it is important that this emotion be addressed to help the adolescent learn to adapt to societal expectations. Parents’ will only reinforce this behavior if they do not address the behavior. If a child appears concerned about his anger outbursts, they will need to improve on their problem solving skills, triggers to anger, self talk, and relaxation skills

School Refusal

It is not unusual for a child to wake up on a Monday morning and complain about having to go to school. Most school age children when given the choice of fun (weekend) or learning (school), will choose fun. However, when this argument becomes intense, persistent, and frequent, we have a behavior that is described as school refusal. School refusal is when a child refuses to go to school, is frequently unable to stay in school for the whole day, or goes to school and leaves or needs to be taken home. These complaints could be direct, through verbalizing not wanting to go to school, or indirect such as physical complaints. The most frequent age we see this occur is between eight and thirteen years of age. However, any school age child could experience it.

When a child refuses or resists going to school, one of the first tasks we need to examine is the reason why he/she may be resistant. We need to rule out confirmable physical illness and mental health issues (i.e. depression). If those do not appear to be a reason, we can look at other areas. This would include peer group (encouraging to ditch school), drug/alcohol involvement, grades, choosing to do more fun things during the day, or worries/fears. A child may be resisting or refusing to go to school because they are afraid. The fear could derive from several areas: fear of a person (bullying for instance) , fear of leaving someone (separation anxiety), fear of situations (being around other people), or fear of an event (speaking in front of class).

Age, peer group, and history of the child are necessary information in determining motivation. Family history or events could also play a factor. If there is turmoil/conflict at home, this could impact on a child’s emotional stability. If there is a family history of anxiety, this may make the child more likely to have anxiety themselves.

Regardless of the reason, it is important to remember that the longer you wait to address these concerns, the more difficult it will be to get your child out of these thinking and behavior patterns. Whether their fears are real or imagined, there is a strong likelihood a pattern of feeling (somatic and emotional) and behaviors will solidify themselves. This pattern, the longer it goes on, the more challenging it becomes to undo. It is usually extremely important to involve school personnel in addressing school refusal concerns. They will be your biggest allies in overcoming this issue. If the school refusal persists, it is important to seek out professional help. A plan of action and working with support systems available are important steps to take.

Common Responses to Trauma

People reacting to losses or trauma tend to go through a set of ‘stages of grief’ which would include denial, outrage/anger, working through, and resolution. These stages don’t always occur in this order, and may happen at different time intervals. We briefly describe these stages:

Denial: You can’t believe that this is happening, it seems unreal, like a dream. The impact of the event has not been fully absorbed.

Outrage/Anger: You are furious outraged at the event. You are hurt and may find yourself crying. You are sad and angry. You feel vulnerable and are looking at someone or something at which to direct your anger.

Working Through: This happens over time. It is the process of sorting feelings out so we can return to ‘normal’. Many different feelings may still be surfacing but there is more of a stabilization of emotions.

Resolution: This is a relative term. This does not imply that people will get over or forget about these events. What it means is that they will have worked their way into more of a regular routine.

Some Symptoms of Trauma Difficulties

The intensity and reaction to these events may vary from person to person. Individuals may be more affected by this event than others. Below, we move listed some symptoms individuals may experience. To some degree, most of us will experience these symptoms. However should a person become ‘stuck’ in these reactions or they interfere with daily life activities. In some extreme cases, these symptoms last several months after the incident.

Physical Reactions: sleep difficulties, fatigue, headaches, muscle pains, change of appetite, dizziness, rapid heart beat, and forgetfulness.

Emotional Reactions: Anxiety, feeling vulnerable, anger, easily startled, flashbacks or reliving the event, low motivation, fearful, feeling jumpy, and feeling on edge.

Other responses: nervousness, isolating, preoccupation with event, problems at work, irritability, increased conflicts with others, and moodiness.

Coping Strategies

• Encourage but do not force talking. With the intense focus on this issue, we may need our periodic breaks from this. By forcing the issue, it may increase the likelihood of feeling overwhelmed about this incident. We should all set our own comfortable pace in discussing this issue.

• Combat the feeling of helplessness by volunteering to help victims. Call 1-800- GIVE-LIFE (1-800-448-3543). Talk to others who are willing to talk about it.

• Keep regular routines as much as possible.

• Maintain nutrition and good eating habits.

• Exercise regularly.

• Sustain good sleep habits.

If you are having continued difficulties with this event, it would be a good idea to talk with your therapist about it. He\she may be ale to give you additional support or ideas to cope with this. As the healing process continues, it is important that we support each other through this traumatic event

Decision Making

Unavoidably we are faced with major obstacles in life. These obstacles could take form in relationships, employment, or other areas. Decisions need to be made regarding what course of action needs to be taken. We invest a great deal of time and energy in trying to make these situations fit the conclusion we want them to. The end result that we desire may not be realistic or achievable. The investment in time and energy in cases such as this, could be better used in working towards a different focus. Below are three choices we have in addressing these obstacles. It is important that you understand these three options are choices you have. Which one you choose is ultimately your decision. Realizing that there is more than one option is helpful for most people who feel “stuck”.

Change: The situation in which you currently find yourself is uncomfortable and you desire to change it. There is some ability to alter the situation. The party(s) involved are willing to negotiate or compromise a solution to the problem. This does not mean that other party has to do all of the changing. It just means that there is a possibility of change. Situations that would fall under this would include: a spouse that would be willing to cut back or eliminate his\her drinking, a supervisor who may be willing to adjust his\her attitude towards you, or a family member who would be willing to stop being critical. Your time and energy is invested towards changing the situation so it can be more tolerable. Compromise is included in this area.

Adjust: The situation in which you currently find yourself in could not be modified. The individual or situation involved is not open or willing to change. You accept the limitations of the obstacle and choose to direct your time and energy into adjusting to an uncomfortable and unchangeable situation. The adjustment comes in knowing you can’t change the situation and accept your limitations. This also means that for whatever reasons, you are choosing not to leave. These reasons could be based on financial, emotional, or other reasons. This does not mean you condone what is going on but just accept you can’t change it nor are you ready to leave. Situations that would fall under this include: a spouse who most likely will not stop drinking, an inflexible supervisor or work situation, or a family member who refused to stop being critical. By choosing to focus in on this area , you have decided that you can endure this situation and you are not compromising your values.

Leave: The situation in which you currently find yourself in is unacceptable. You realize that by staying in this situation, it is going to be too uncomfortable for you. The situation will most likely not change and it would be too difficult for you to stay . Your energy is best utilized towards a transition and leaving rather than adjusting or trying to change it. Examples include: a boyfriend\girlfriend that is physically abusive or a job that has no future.

It is helpful to understand that if you commit to one of these directions, to realize the behavior that would accompany this decision. The behavior to prepare for comes from both you and the other party need to be consistent with the direction you choose. If you are putting your energy into adjusting to an alcoholic spouse(not wanting to leave the relationship and identifying change may not in the near future), yelling at him\ her, would be inconsistent with the decision you choose. Same could be said of deciding to complain to a boss about a performance evaluation you were rated poorly on, after deciding to take another job. Expecting certain behavior that is inconsistent with where you emotionally committed, could lead to confusion and additional stress.

Legal But Not Safe: K2

Some individuals have gone to great lengths to experience altered states or “highs.” When we think of getting high, the images that comes to most peoples mind is illegal drugs or alcohol. That is not always the case. There are legal or easily accessible items that could be used to induce a high. The methods used may include inhaling household products, inhaling gasoline, abusing prescription and over the counter medication, and various products advertised at Head Shops (local retail shops that specialize in drug paraphernalia related to consumption of cannabis and other recreational drugs).

If a product is legal, it may not mean it is safe. A new trend is synthetic marijuana, K2, Spice, or fake weed. It looks similar to marijuana and individuals who use it would not come up positive on hair analysis or urinalysis. This product can be legally obtained over the Internet, Head Shops, or even gas stations. It was first introduced around 1990 but in the last few years has become more popular. The ingredients include a chemical made to mimic THC (the main chemical in marijuana that produces the high). The producers of this imply in their advertisements the drug is organic but that is not the case. The component that produces the high is made in a laboratory.

Due to it’s relative newness, there is not a lot of data out on the long term effects it produces. We do know that some studies indicate the high is similar to that of marijuana but may not have the long term effects of a marijuana high. Some of the side effects may include feelings of paranoia, anxiety, and depression. Just like other potential drugs of abuse, there is the concern that individuals will rely too much on it for relaxation or to reach the desired effects. This prevents individuals from developing their own methods or coping skills to address personal issues.  There are not any legal regulations on making this product , at this time, and some of the chemicals may be mixed in home laboratories resulting in imprecise mixtures that could make the effects of its use unpredictable and even dangerous.

There are some states that have banned it or have introduced legislation to ban it. Parents could help address this issue by talking about it with their children. Rather than focusing on whether or not the product is legal, we may miss the point that the drug is harmful to children. 

When Siblings Fight

There are very few parents who have not experienced some sort of sibling rivalry amongst their children.  In fact, developmentally, it is normal. Children learn problem solving, compromise, and sharing by working out differences with one another.  However, for some families, rivalries could become problematic and even dangerous. Factors that may impact the intensity, frequency, and duration of these arguments include: individual personalities, age of children, parental role and role modeling, family stress, constructive/productive free time, and family dynamics.

Children are more likely to get themselves in trouble when they are bored or hungry. Since most children may not be able to express themselves, or at certain ages have good insight into their own self awareness, they may act out on their feelings.  Certain children may not have the disposition to watch or be watched by an older sibling in general, or a sibling in particular. Their personalities just may not click, especially if there is an age difference. Older teens are more interested in being with peers and as a rule spend less time with family. Children may also put or be put in a position of authority, without the ability to carry through consequences as a parent would. If there is a special needs child, a sibling may be ill equipped to handle disciplinary issues. Also, parents who resolve their own differences through yelling or screaming, are teaching their children to work through their problems the same way.

Family stresses such as divorce, relocation, and illness will also impact sibling relationships. Children may act out on their stress rather than verbalizing or trying to work through these issues. If parents are experiencing stress, this may take away their time and ability to address issues as well with their children. Oftentimes, rivalries are intensified by competition for parental attention. A parents role is to help children learn the skills to work through these issues. Important problem solving skills could be developed by encouraging children to compromise or negotiate agreements with one another. Not all issues between siblings can be resolved at any given moment.

Children who have had much discord at earlier ages, become good friends later in life. Parents can help their families through this time by:

● Making sure you treat each child fairly and consistently
● Be proactive: determine times and places these rivalries play out and plan for it.
● Be consistent with nap times and snacks
● Set times up parent times for each child if possible.
● Pay attention to conflicts and make sure children are heard.  Being heard does not  mean agreeing but acknowledging their point of view.
● Present it as a family goal to get along better with one another better. If consequences and incentives are laid out, children may be more invested in changing their behavior.
● Set clear ground rules and consistently follow through with consequences.  If the family is going through stress, talk about it and normalize it. Offer your children an opportunity to express themselves.
● Monitor your own response to conflict and how kids may learn from this.

It is human nature for some conflict to exist between siblings. If the issues persist, it may be helpful to discuss your concerns with a professional therapist.