Why I’m not a behaviorist

Content: general discussions of substance abuse, overdose, psychiatric hospitalization

Quick disclaimer, my goal isn’t to discount anyone’s successes with behavioral therapy - I know people have found them helpful and life-changing. I want to share my perspective on why strictly-behavioral therapy runs contrary to my intuition and experience as a counselor.

In 2009 when I was getting my master’s degree, I was an intern on an inpatient acute care unit that was part of one of the largest hospitals in Arizona. One wing was for patients with potentially severe mental illnesses like depression, bipolar disorder, and schizophrenia. The other was the substance use wing - people who had overused or OD’ed, intentionally or otherwise, and needed medical stabilization as well as therapeutic care.

Most of my work was on the solely mental illness side, but occasionally I’d be assigned a patient who was admitted for substance use. Either way, my job, under the guidance of my supervisor, was to be the clinical touchpoint person for patients during their 5-7 day stay on the lockdown unit. I also printed one-page paper discharge plans for clients to take home, which were copied and pasted from a template depending on a person’s diagnosis.

A few months into my internship, I was assigned someone who had been admitted for alcohol detox. The first few days he was on my caseload, he slept. I’d try to interact with him, only to come back to the office ten minutes later with no new information about this patient.

Eventually he sobered up, stabilized a bit and could carry on a conversation. We talked about the events that led up to his hospital stay. He had been through some really heavy shit, and while he said he wasn’t trying to hurt himself or feeling suicidal, he knew he wanted to drink to black out - to not feel his feelings.

I listened, empathized and processed with him the feelings behind his decision to drink as much as he did. The past few days hadn’t been an isolated event, I learned. He was dealing with a lot of trauma and had no real support, and alcohol made sense as a way for him to get through this stuff.

As he neared the end of his hospital stay, I pulled up the substance abuse discharge plan. I copied and pasted the information we gave everyone, advising him to follow up with his PCP and a 12-step group, some information about addiction, and what to do in the event of a crisis. Before printing it out, I added some resources on general mental health care - support groups for depression, websites where he could find more information about coping with trauma and how to find a counselor through his insurance. Even though this client didn’t have anything other than a substance use diagnosis formally listed, I knew he needed more.

My supervisor glanced it over and was about to sign off when he looked at me confused. “Why is this on here?” he asked. “This is an SA patient. He doesn’t need this information.” He seemed confused, which confused me.

I explained that the patient had been through a lot and that he needed the resources. Anyone who’s drinking that much, I reasoned, is clearly not doing well mentally or emotionally (regardless of their diagnosis or lack thereof).

“Change it back to the standard SA discharge plan,” he said. Not having the wisdom or courage yet to speak up to someone in a supervisory role, I swallowed my frustration and embarrassment and redid it. I handed the client a discharge plan that had no information on how to get help for depression or trauma - just “try to attend 30 meetings in 30 days” (this was literally part of the exact wording).

I remember standing in my supervisor’s office and his look of confusion plus a touch of disdain at what seemed to be my naïve reasoning. I remember wondering if I just hadn’t learned yet why substance abuse isn’t a natural outgrowth of emotional health gone seriously wrong.

All these years later, I still haven’t learned whatever he was trying to teach me that day. If we were having this conversation now, I’d be looking at him confused. Because in as many years as I’ve worked with people who have addictions and/or substance abuse issues, I have not met a single person who wasn’t trying to numb out from something deeply painful. I’ve listened to enough trauma stories to look at a client and say “well no wonder you wanted to drink; who wouldn’t want to numb out from all of this?”

For me, full circle looks like walking someone through acknowledging the need for survival, honoring the addiction and even honoring the substances themselves with gratitude. Because feeling everything at once would have been too much. Because keeping some sense of emotional safety by numbing was the only option available. And the fact that this person is sitting in front of me now, asking for help, is validation that they were doing the best they could with the resources they had at the time.

My focus with anyone, regardless of whether they have a substance abuse diagnosis or problem, is never on their behavior. It’s on the roots. How did we get here? Why did we get here? What stories do we need to tell, process and reframe? What new narratives can we create and strengths can we build on? The changes a person wishes to see in their behavior will flow from there.

Trusting that process is hard. But you don’t have to do it alone, either.

Thinking about making a real, lasting change? Ready to get started? Let’s talk about how I can help. Text or call me at 602-601-2062 or email janae@getrealcounseling.com. I can’t wait to hear your story.