I enjoy working with these clients. I see them as a sub category of substance using clients, not all those using are misusing, in a personal sense, only in a legalistic sense. Few people wilfully misuse substances long term. There are reasons. Teasing out those reasons, and helping a client find a new path of their choosing is extraordinary, though rarely easy.

Dear Dr. Berkeley,

Just today I read your question. For several years I stopped working with substance misuse clients (I mean, addicts), for a personal choice. Throughout my work, I realized that my clinical results were was far below what I had with other diagnoses, although wear with that work was greater. I understand that, parallel to the structural issues that underlie this pathology, there are severe contemporary cultural issues that go against the successful outcome of the assistance to these patients. Among them, the so widespread refusal to postpone satisfactions, leading to a lack of mediation between desire and act, as well as the excessive medicalization of human difficulties, which creates a tendency to a "chemical" resolution of emptiness and suffering inherent in being alive.

Dear Dr. Berkeley,

For the last 6 years I have been the Director of Inpatient Detox Services at a safety net hospital located on Long Island, New York. I am not familiar with the term ‘misusers’. Unfortunately, Long Island is fighting an epidemic. IV heroin use (dependence) and opiate use (dependence) is rampant with no end in sight.

News media and local politicians do not see or understand the scope of the problem. I’m not sure I do either. As an inpatient unit, average length of stay is 5 days. This does not provide a milieu that allows for in-depth patient/clinician interaction.

Satisfaction in working with this population, in this milieu, must be reshaped. Working in crisis mode everyday demands this. Having a patient agree to ‘the NEXT phase’ in treatment is the most my staff can expect. Success for addiction is measured in achieving sobriety for X time. We rarely see our successes. We often see the results of the high relapse rate of patients with addiction.

I would be interested in having a better understanding the population you refer to as ‘misusing’. Also, are you seeing an increase in opiate use?

I hope some of the above makes sense. I am writing this as a means to maintain my own sanity. Living in the path of superstorm Sandi and having survived (overstating the obvious) my own reality is settling in. No electric for 6 days now with no end in sight. I have been able to get to the hospital every day but now gasoline is becoming a problem. There is none. Devastation all around. Sitting in town hall to get warm, recharge phone and keep reality at bay.

A difficult time for all of us,

Kevin Coleman LCSW

Sounds like a shocker. My sympathies are with you.

I wonder about about success being measured only in sobriety. What about reducing harms from use?

Kevin, you have my deepest sympathies. I'm a dual national, American British, and many of my family still live in New York and New Jersey and are experiencing exactly what you are. The one consolation that I know my family focus on is that you do live in America. The power will go back on eventually, you will have gas for your car again eventually, the mess will get cleaned up eventually. What no one can clean up is the acts of unkindness towards others, looting, and other bad behaviour that may possible be seen before normality is restored. Sadly, there is great potential for numerous field experiments and studies for social psychologists et al.

I must correct you and Eder Schmidt, though I'm flattered - I'm not "Dr" Berkeley: yet! I'm a Trainee Counselling Psychologist in the United Kingdom (I've lived here for 38 years) with about two years of training (+/-) to go.

In the UK, we use the term "substance misusers" more frequently as it seems to acknowledge that we all use substances. Do you enjoy your coffee in the morning? Do you smoke tobacco? Do you ever have a glass of wine? Take an aspirin for a headache? I'm sure I don't need to labour the point. Substance use becomes misuse when it creates a problem for the individual whether psychological, practical, intra or interpersonal, financial, or in any other domain. I enjoy my two cups of coffee in the morning but they don't cause issues for me.

I do, of course, accept your account of your direct experience. To those on the front line, the UK government's claims that drug/alcohol use is going down are laughable (http://www.nta.nhs.uk/) and any similar claims made in America must feel the same way for you. Much of what you go on to say relates to Elizabeth Merrilees simple comment and question, "I wonder about success being measured only in sobriety. What about reducing harms from use?"

Even our politicians are now conceding that we have "lost the war on drugs". I can appreciate that working in an inpatient unit, you have come to use the medical model's language and perhaps have your own reasons for believing the medical model's framework. As a Trainee Counselling Psychologist, and I think anyone from Division 17 would agree with me, we call people clients, not patients, and we don't impose the therapist's goals on the client. The medical model's answer to the issues (detox solves all ills) clearly doesn't work. 12 Step programs don't either, not long term. For some they do and I would never discourage someone from attending detox or a 12 Step program if that works for them personally. But on a statistical basis, the problems resembling Hurricane Sandy, something isn't working. In CBT language, isn't it time to do something different?

Here, we have been practicing more of the harm minimisation approach for a very long time, which may not help the client to achieve our goals (abstinence) but does provide a rationale for what you have observed ("Having a patient agree to the next phase in treatment is the most my staff can expect"). Substance misuse is a maladaptive way to self-sooth and because it's maladaptive, will always include many lapses/relapses; put another way, many descents up and down the spiral of the transtheoretical stages of change (Prochaska, DiClemente, & Norcross, 1992). The practitioner/therapist, to work in this field and not become burnt-out, has to initially get their head round the idea that they won't see many successes and may see none at all if success is always measured in sobriety and nothing else. In the harm minimisation model, an albeit small success would be seen as getting someone to quit snowballing and just shoot up heroin; then persuading them to smoke it instead. Unfortunately, harm minimisation has become associated in many minds only with methadone maintenance, and actually there's very much more to it. The goal, which the practitioner/therapist should acknowledge explicitly to the client, is to retain clients in some sort of treatment by respecting their autonomy and right to choice, even if that choice is to snort themself to death.

The medical model sees detox as potentially solving the problem because, since addiction is physical, getting the drug/drink out of the system should cure the person - right? No, this is just a first step and doesn't solve anything because this doesn't address anything about why the person was using. 12 Step responds hysterically, seeing "Evil" printed on every bottle and joint when many people drink alcohol sensibly and it causes them no issues; young people have been experimenting with the forbidden since time began and a few joints don't always or necessarily mean a life of heroin addiction and degradation. I know many researchers like to poke fun at Khantzian's (e.g. Khantzian, Mack, & Schtzberg, 1974), self-medication hypothesis, refusing to acknowledge that he revised his theory (retracting the idea that the substance of choice is directly linked to the type of psychosis or mood disorder but is linked to the relief of a specific symptom to achieve affect regulation, e.g. Suh et al., 2008). In the case of certain researchers, I suggest that this may be due to envy that they didn't think of it first. However, clients report themselves as self-medicating and understand what many treatment programs don't - that they began using to a problematic level in the first place because of psychological issues, not because of some inherited compulsion or drive to do so. No five year old says to themself, "I want to be a crack addict when I grow up" but they may wish Daddy would stop beating them for crying.

The saying goes that "When America sneezes, England gets a cold". I'm very concerned that the UK in desperation at the scope of the problem is retreating behind the cloak of heritability and abstinence, borrowed from America. For further discussion of this issue, I strongly suggest Stanton Peele's (1999) "Diseasing of America" (http://www.amazon.com/Diseasing-America-Recovery-Treatment-Industry/dp/0787946435/ref=sr_1_1?ie=UTF8&qid=1352036986&sr=8-1&keywords=diseasing+of+america) for a further discussion of this.

However, a recent development here has been surprisingly enlightened. The Social Care Act (2012) basically says that substance misusers can no longer be denied psychological treatment, the traditional separation between mental health and substance misuse services being dismantled. Our Improving Access to Psychological Therapies (IAPT, 2012) came out with a document stating this precluding the Social Care Act earlier in 2012. It is with great glee that I now inform clients of their right to no longer accept "go away until you've stopped using" or "go away until your depression is treated" which left them with no therapy or treatment, "falling in the cracks".

I originally asked my question here as I have done a study to discover if UK Trainee and Registered Counselling Psychologists prefer not to work with substance misusers and if not, why not, as I was hoping to get some comments here to think about. The study was closed before everyone started replying but the discussion we're having is still useful. (The study turned up some interesting results and we're hopefully going to publish them so watch this space!). We may never find what works but we do need to find what works better than what we have now and design training for both psychological therapists and substance misuse practitioners that not only allows them to use evidence based therapies to work with people holistically but protects all substance misuse practitioners against burn-out and dismay with the work.

i would suggest Linda you might publish this as an editorial piece. it is a nice description of AOD work and principle. thanks.

i have to say, i have spoken to many psychologists and psychiatrists who will not or can not work with individuals using alcohol and other drugs. so frustrating.

i had a devastated client say a lecturing psychiatrist at her uni tell a hall full of psych undergrads that all alcoholics were the same, they were all liars, and students would quickly realise it wasn't worth working with them! as an ex-alcohol user she was crushed.

What an absolutely stupid remark and a cruel thing to say. Another thing a CoP would never do, or rather, should never do, on the basis that you never know if someone is in the audience/group that you'd not just offend but hurt terribly. I hope you told your client the psychiatrist is full of ++++.

The "inspiration" for my study was exactly what your experience has been - that many psychologists (and psychiatrists) won't work with substance misusers. I told a lecturer that I wanted to do this eventually (having an extensive CV in the field) and was shouted at, yes, shouted at, "YOU'LL CHANGE YOUR MIND!" I was 55 years old when I was told this - I would never speak to a child that way!