Trauma

There has been a greater focus on trauma this week at Samaritan Inns. Having reread the article on groups with clients with a traumatic history, there are a number of correlaries and outstanding issues I have.

The most relevant issue raised by the article was the stages of trauma groups. At first, the focus of the group should be on readjusting the client's perceptions and thoughts in the present. I understand this need, but it wasn't clear in the article if this type of treatment should occur directly after treatment or upon admission to treatment, even years later. In my field placement, all clients have undergone major trauma. However, for most of them, the trauma was years ago. Since then, they have tried to maintain equilibrium through substance abuse, which in turn retraumatized them many times over. Should I be dealing with the acute concerns in the here and now or delve deeper?

Devling deeper would involve catharsis, which the clients seem to crave within the groups, and abreaction. Because I am unsure of the directions in the article, I don't know if this level is appropriate for my group members. This is a substance abuse group, but issues around trauma have become paramount in this stage of group development. Ultimately, the client will dictate their openness to exploring those feelings. The comfort, understanding, and self-efficacy they will build as a result of exploring these feelings either in the "here and now" or "there and then" is the most important aspect of these groups.

Roles

In the Intensive Recovery Program, the group structure and expectations are unique. The group is expected to hold each member accountable for their behavior, at times with confrontational "pull-ups." An older client, D, expressed her ambivalence about the confrontational style. Her behavior during the group, in which she addressed another member's behavior pattern of nitpicking other clients, was passively confrontational and designed to hurt. During her "pull up," she addressed the client's psychiatric diagnosis, a detail that should not have been shared, and tried to enlist other group members in her cause. This behavior did not match with her supposed opposition to confrontation.

Another counselor and I were leading the group in order to openly address these interpersonal problems, which came to our attention during lunch. When confronted, D not only maintained her opposition to confrontation, but criticized the group norm of holding each member accountable. She stated that she was only responsible for her behavior and the behavior of others. The other counselor agreed, stating that she is merely accountable for others' behavior. D expressed confusion about the difference between accountability and responsibility in spite of the patient efforts of the other counselor.

In order to elucidate the concept and give her perspective on her interactions with the group, I asked her what her role was in the group. She gave a circuitous response that directed the question back to her opposition to confrontation. Undeterred, I pressed her for behaviors she exhibits in the group and a metaphor for them, such as caretaker or scapegoat. She still could not think of any, so I offered a suggestion of my own, the caretaker, as she is the eldest of the group and tries to nurture others. I then connected her role with the reciprocal determinism of group interaction, in that the group impacts the individual as the individual impacts the group. This is why you are accountable for others' actions and why the counselors insist upon the maintenance of those group norms.

Children of Alcoholics

This week's reading on children of alcoholic parents was especially relevant to the population I work with.  The majority of the addicts in the Intensive Recovery Program have children, and most were raised in a family with substance abuse problems.  For many of our clients, the interventions spoken about in the reading would have helped them greatly.  The one that spoke most to the need presented by the clients were the education and implementation of effective coping skills.  I believe addiction is a maladaptive coping skill (not a disease).  I witness the poor coping strategies of clients mentioned in the article, such as perfectionism or internalized defeat.  From this article, I have gained information on how to treat alcoholism by teaching clients emotion and problem based coping strategies.

The interaction between substance abuse and family was further highlighted while I was completing my program assessment for another class.  I was speaking with the coordinator of the Intensive Recovery Program and she expressed her frustration that families could not play a significant role in our treatment model.  During the first 28 days of treatment, the clients are not allowed to contact anyone, let alone their family.  If the client is accepted into the transitions program, he or she is strictly limited in the time spent with their children.  Even in the Singe Room Occupancy program, for which the clients interview after 6 months in transitions, family visits occur rarely and count towards the total number of visitor hours one is allowed.

Race, Culture, and Competency

In reading the articles for this week's class on racism and cultural competency, I saw many parallels with my work at Samaritan Inns. Many of the concerns expressed by the family members in the studies were also expressed, although less often, by my clients. When most clients enter the facility, they are greeted by a staff who are (almost all) African-American and recovering addicts. Many of the staff are also from the the same neighborhoods as the clients, allowing them to connect with the clients without any real effort. They can just drop some lingo or the name of a crackhouse that's still operating and the clients will immediately relate to them as an authority on addiction. This is not the case with me.

All of the clients with whom I work are African-American and none share significant cultural similarities with me. Yesterday, we received some new clients as some of ours had transitioned over the weekend. I was co-facilitating a group with another counselor on the rules and expectations of the program. At the close of the group, she related her story of addiction and told the clients how much they would connect with her and the other staff members "even Matt" while in treatment.

Now, I wasn't offended by this method of inclusion but it further cemented my position as an outsider in this placement. The drawbacks of that position are the clients' judgment that I cannot relate to their story of addiction and that their story might be 'too much' for me. Luckily, this sets the expectation bar pretty low, and when I do lead a group, they are surprised with the insight and guidance I can offer them. Another surprise is that their story, however horrid and tragic, is not going to be something that shocks me into the fetal position.

Empathy and Boundaries

In my field placement, there have been two incidents where I have struggled to balance the usually complementary concepts of empathy and boundaries.  The two situations happened after a negative interaction with a staff member during group.  After the group ended, I was able to speak with the client privately so they could vent their emotions and gain some perspective.  During each interaction I was confronted with issues relating to empathy and boundaries.

In the first interaction, already described on this blog, the client expressed hurt and anger, which I felt to be righteous.  Although the client often whiles and pushes limits, he was without fault in the interaction and very little could be said in the clinicians defense.  However, I could not completely side with the client against the clinician because that would violate my boundaries.  If I had done so, the client would no longer see the staff as an integrated unit, but a divided one maliable through power games.  Much like parents, a clinical team must appear united and process conflict privately.  Because of these contraints, I felt limited in my capacity to empathize with the client.  Perhaps, I was just being overly cautious.  

In the other instance, a different client was falling sleeping through groups--a violation of the rules.  The same clinician reacted patiently the first few times, but again lost her temper.  The client nearly walked out of the program crying.  After the group had ended, the client asked to speak with me about her wanting to leave the program.  While I was able to reach the core issue (her self-sabotage and fear of accomplishment), I found myself stepping out of the interaction and thinking of the levels of empathy described in the textbook.  Whereas the other clinician had used the lower levels of empathy by offering advice and simplistic answers, I tried to use the higher levels of empathy by relating the clients moment-by-moment feelings and helping her to access feeling words.  This interaction was by far the most positive one I have had in my field placement thus far.

Ethics

Over the past few weeks here, I have observed some less than stellar clinician-client interaction. Yesterday, a counselor here started an argument with a client over donating a Safeway gift card to the common pool of cigarette money. There were many conversations going on simultaneously and the client did not know what she was requesting of him. The counselor refused to explain her request and the client refused to comply. Later on, while I was leading a group, the client raised the issue of quitting smoking. He wanted to stop smoking and wanted to announce it to the group. The counselor, upon hearing this, clarified that his smoking privileges had been revoked because of the previous argument. The client was attempting to usurp the power of the counselor by quitting smoking. As this is the main punitive measure here, the client was deftly starting a power struggle between himself and the counselor.

The counselor sensed she was being had and then proceeded to do what is ethically indefensible. She went on a ranting tirade about the client in which she berated him for lying, stealing, and other relapse behaviors. The client was not permitted to speak through this interaction and lashed out in some passive-aggressive ways (sighing loudly, tapping on his chair, having a smug smile). After that interaction was over, I closed the group that was interrupted and did a life-space interview with the client. I engaged him socially, as well, in order to deescalate the situation. Although I feel I did all I could, this is a persistent problem with the staff here. There is an emphasis on confrontation in the literature, but this confrontation was neither therapeutic nor rational. The client was in the right and felt victimized by the system. I can only hope that this incident does not threaten his transitional work.

Educational Group Part 1

Yesterday, I conducted my first educational group at Samaritan Inns. It was on the stages of change and the role of intrinsic/extrinsic motivation. I researched some theory on my lunch break and presented the easily understandable parts. Unfortunately, I did not get to finish the group and translate planning skills into psychological progress.

This group really brought up issues of authenticity. While I believe I facilitated my group authentically, I feel that my overall impression is inauthentic. I am a 23 year old graduate student talking to adults about planning to get a job. I just don't feel like I'm connecting at a gut level. If I am speaking about addiction and recovery, I feel somewhat fraudulent in offering an opinion. On psychology grounds, I am much more comfortable with my knowledge.

The theory itself was quite interesting. It broke down the process of change into distinct stages. I feel like the clients here are merely adrift in their psychological processes and do not have the skills to progress on psychological issues. They speak in platitudes, some of which are provided by A.A., and do not have a true, deep connection with their future. The only thing they can connect with is their past. I especially liked this theory because it was a client-directed version of assessment and planning.

Theory

As I read through the literature and observe the groups at Samaritan Inns, I am increasingly disturbed by the approach of this facility. Although other parts of the program are client-centered, the Intensive Recovery program requires strict obedience and adherence to the 12-step method in order to successfully recover. This program promotes the ideas of individual powerlessness, god-directed life, and shame. The first step is admitting you are powerless over addiction, which diminishes individual agency and efficacy in recovery. After performing some research, I learned that Alcoholics Anonymous was founded on the principles of god-control, advocated by a Nazi sympathizer, Frank Buchman. More disturbingly, the method also induces shame in the clients by telling them they have "character defects" that only a diety can remove.

After learning about the theoretical approaches favored in modern social work, I began to wonder what year I was in. The client-centered, evidence-based, strengths-based approach I was being taught in school was being outright ignored in my field placement. Rather than protest, I simply choose to approach the work at Samaritan Inns from a different perspective than my coworkers. I feel like I can engage better with them by preaching less and listening more. I don't see how this facility could ignore self-efficacy and mutual respect as foundational tenents of a therapeutic relationship.

Optimism

After the first weeks at my field placement, I am very optimistic about my position at Samaritan Inns. They started me out by observing group therapy and training me to do intakes over the phone. Although I am not taking part in any of the treatment, they are eager to integrate me into the program.
The staff is in flux because on alternating weeks, people have been going on vacation so I'm working with the night faculty covering shifts during the day. My coworkers themselves are interesting in that they are almost all former addicts who have successfully recovered. In addition to the skewed demographics of the clients, this alienates me from most of the people in the program. This works to my advantage, however, in that none of the staff in the Intensive Recovery Program have any psychology knowledge beyond addiction counseling. They are coming to me with questions on dual-diagnosis cases and psychological treatment histories. It's a little embarrassing because I don't feel qualified to give an opinion.
Unfortunately, since I'm essentially waiting for people to call for intakes, I have a lot of free time. To occupy my time, I have begun to read the Alcoholics Anonymous and Narcotics Anonymous literature in the office. I didn't know that the program used a strict 12-step method of treatment. My only previous exposure to the 12 steps was through a Penn & Teller: Bullshit! episode that was highly critical on psychological and religious grounds. Then again, they did a Bullshit! Episode on global warming that was pretty false, so it's possible they're just being myopic. This is going to be interesting.