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When do psychosocial factors become an excuse for continued substance use? While this section is not to dismiss the importance of psychosocial forces in shaping the individual’s substance use behavior, can psychosocial factors just become an excuse for continued substance use?  Consider the following hypothetical interview between a substance abuse rehabilitation counselor and an alcohol-dependent person in treatment for the 4th time:

Counselor: We are meeting today to try and develop a plan that will help you abstain from slipping back into active drinking after you are discharged from treatment.  Do you have any ideas on this subject?

Client: Well, you have to understand that Mom was quite abusive when I was growing up.  My father left us when I was about one [year old] and I guess she just took it out on me.

Counselor: Yes, I’ve read your past records and from what you have told me in our sessions it does sound as if she was an abusive woman.  But that was thirty-eight years ago.  The issue before us now is how we can build a recovery system to help keep you from relapsing after this treatment program.

 Client: Well, I feel pretty uncomfortable asking for help.  I don’t have any self-esteem to speak of...

 Counselor [breaking in]: So it seems that you are saying that one thing that would help is being able to practice asking for help.  That is a skill that we can help you learn, here.  We can role-play a variety of scenarios so that you can feel comfortable asking for help if you should feel the urge to drink.  Can you think of anything else?

Client: Well, I don’t feel comfortable being around many people. I prefer to stick with my friends.  I know them and do not fear being rejected by them.  We’ve been friends for a long time.

Counselor: If I understand what you are saying, then it would seem that learning how to build friendships with people who are not drinking is another skill that you would like to work on...

Client: Well, I was beaten up by my mother quite a bit when I was a kid, and I don’t find it easy to trust others.

Counselor: All right.  You seem to be saying that you want to learn how to trust others: The signals to look for in a person who perhaps cannot be trusted, signs that a person might be trusted, and how to build a healthy friendship or friendships.  These are good starting places.  Can you think of anything else?

Client: Well, no, I can’t.

       In this interview, notice how the client kept trying to blame his alcohol use disorder on the abuse that he suffered as a child.  The counselor, however, while not dismissing the reports of abuse by the client, kept the focus on what will help you abstain now rather than looking for root causes of the client’s alcohol use disorder.  This hypothetical client has been in treatment on three prior occasions, and searching for the root cause of his alcoholism has not helped keep him sober.  However, from the client’s presentation it does sound as if he had learned to use his past as a way to rationalize his drinking.  So, by keeping the focus on the here and now, this problem is avoided and treatment can start to focus on what the client needs to learn to help him stay away from alcohol now and in the future.

Questions

  1. “If you focus on the negative, than only the negative can emerge from treatment” Do you agree with this statement? Why or why not?
  2. Do you think that the treatment approach presented in the above dialogue is a valid one in light of this client’s history?  Why or why not?

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