CAB Health and Recovery
In 2002, my first year internship for Simmons was at CAB Health and Recovery Services (CAB) in Salem and in Danvers, MA. CAB is an agency focused on providing services for client recovery from substance abuse and dependence. I had a CAB supervisor assigned to me, someone who had the required LICSW license. We met weekly to review my experience including process notes that were required for school.
Initially, I worked in CAB’s outpatient clinic seeing drug involved adults individually and in groups. Some clients were still using illicitly and others had been abstinent for durations ranging from one hour to five years. Most of the individuals I saw already had had multiple therapists; my clients were far more experienced with therapy than I was! Generally, they were patient with me because they already knew how to get their own needs met, including telling me how to be helpful to them. There were interns from other schools at CAB also, and we formed our own supportive community. CAB employees, therapists and administrative staff, were friendly and helpful.
I participated in two groups for adults. One was a court mandated group for people caught “driving under the influence” (DUI) of alcohol or drugs. While the participants had no choice but to attend this group, I found the group to be composed of people who were mutually supportive and respectful to the agency staff. Participants discussed their life situations and events in group, expecting and receiving emotional support from one another. It was a valuable, positive introduction for me to a well run, effective group.
The other group was more problematic. It was for individuals trying to get sober, recently sober, not trying to get sober, court mandated, and voluntary. The CAB group leaders were either working fee-for-service or had productivity requirements. They were incented to service the large group while CAB management was incented to keep expenses down. CAB was reimbursed for each client. Margin increased as the ratio of staff to clients decreased. The group leaders sometimes struggled with the size and problems of the group which gave me a view of some of the contradictions inherent in the field.
One day, there were so many clients present for the group that I was left alone to run a group of more than twenty clients, too large a number for any group, especially one led by me, just a few weeks into my first internship. Some clients, perceiving my inexperience, went in and out of the bathroom; I suspected that they were dealing drugs. While this was occurring, another client, weeping, pointed out the window to a location about 300 feet away, and told the group that she had been raped there several months earlier.
Others offered her support but I found myself at a loss as to how to both help her and maintain some order in the group. After that meeting, she disappeared and I worried for weeks about her and about what I might differently. It was several months later when I heard from another client that the client I worried about had “simply decided to take a trip”, had returned, and was “doing fine”.
I was assigned to co-lead another substance abuse group for teens. Some of them had been present where others were drinking but said that they themselves did not. The group was run by the therapist who was also my clinical supervisor. She said that she did not believe in substance abuse treatment. Her psychodynamic psychoanalytic orientation led her to have no established curriculum. At each session she would ask the teens “what do you want to do today” to which they would answer with some variation of “let’s party and get some drugs”. They would then proceed to talk with and over each other on that subject. My co-leader told me that she had met former clients who claimed that her approach was really helpful. I had my doubts and saw that various therapists’ psychological orientations could lead to very different treatments and outcomes.
Unlike the mandated adults who used their time in the group to learn how to avoid repeating the actions that landed them there, the teens seemed focused on doing their time and having fun. A friend of mine with years of substance abuse treatment experience said that he had more success using a psycho-educational curriculum with teens. My co-leader / supervisor agreed to try to impose more structure, but the pattern of the group was hard to change. There were lessons to be learned even by not succeeding.
Agency management, which had offices at the site where the group met, did not seem to care what was going on as long as the teens stayed in the room and nobody got hurt. There was no agency-wide philosophy of treatment. In substance abuse treatment, there were at least two very different philosophies; abstinence and harm reduction. CAB did not choose between them or try to influence the therapists as long as the clients attended and the therapists fulfilled the paperwork requirements. I realized later that this is true in most of agency psychotherapy. Nobody really knows what goes on in the treatment room except the client(s) and the therapist.
At CAB, there were no measures of effectiveness. Nobody tracked what happened to the teens after treatment. It was not clear that the teens needed, or would accept any form of help from us. They had not asked to be there. Their mandated treatment seemed arbitrary to me. Really, the treatment was that they had to show up somewhere that they did not want to be which may have affected their use of substance, but which certainly affected their desire not to get caught again.
My final responsibility at CAB was to see clients individually, who were, for the most part, voluntary. I saw a man in his forties who, I was surprised to discover, “only” used marijuana. He said that he had been using it since his early teens and now felt that it had robbed him of a life, that he had been “in a haze” most of his life, had never married, had kids, or held a steady job. He took recovery from marijuana seriously and at my suggestion started attending AA meetings. He was forthcoming in therapy and, as time passed, proud of accumulating sober time since his last use of marijuana.
I saw another man who said that he was addicted to cocaine. During the six months that I saw him, he was unable to stop using for more than a week. He claimed that our weekly sessions were helpful but he said that killing his dealer might be more helpful because “I don’t know any other dealers”. He never identified his dealer to me and did not seem to be serious about killing him.
Through the groups and these two men, I saw that what was called “addiction” could appear in many forms. The term was a generalized label for problems that included substances. I also noticed that many clients didn’t really want advice from me; they understood their environment far better than I could. Rather, they used me as a witness to their lives and a “sounding board” for their own ideas.
My first major school project related to my CAB internship was to select a client and do a series of five papers including the intake, diagnostic evaluation, treatment plan, interventions, and results. I didn’t realize it at the time, but this project was an introduction to the five elements used in agencies and required by the MCOs. It is a paradigm of treatment that contains implicit views of mental health, human distress, and how to respond to that distress.
The client who I selected was a homeless man staying in the shelter across the street from the clinic. He seemed to be happy to talk with me and told me about his family relationships and his life in general, which included what he called “a love affair” with alcohol that had lasted many decades. He volunteered that his drinking eventually crowded out most other things in his life. He was willing to help me with my assignment.
After doing the intake and diagnostic evaluation parts of the assignment, my client disappeared and didn’t reappear during my time at the agency. Nobody seemed worried; apparently he had done this before. When I told my professor that I would rather not start again with a new client, she told me to “imagine possible scenarios for the next three papers” based upon what I knew of my original client and my experience with other clients.
CAB offered me a job at their methadone clinic, which allowed me to earn some money and continue my internship. The methadone clinic gave me an education for me in Methadone Maintenance Treatment (MMT). MMT seeks to substitute regular, medically prescribed doses of methadone for illicit opiate use, including use of heroin and other opiates procured both legally and illegally. Admission to the outpatient clinic required proof that the client had tried at least twice to stop using illicit opiates through inpatient participation at a “detox” clinic.
Methadone, taken orally to treat opiate addiction, mitigates the effects of opiate withdrawal, lessens the cravings for other opiates, lasts a full day, costs about $13/day, and does not induce as much euphoria as heroin or other opiates. Side effects can include constipation, dizziness, drowsiness, dry mouth, headache, increased sweating, itching, lightheadedness, nausea, vomiting, and weakness. A successful participant in MMT can hold a job and function well enough that, if she was your coworker or neighbor, you would not know about her treatment unless she chose to tell you.
The goals of MMT were focused on preventing illicit use, and therefore the paperwork involved in seeing MMT clients was not too burdensome. The treatment plan was regular attendance and participation in dosing and therapy. I was required to write up session notes and group notes. My new clinical and administrative supervisor was the MMT clinic director who was knowledgeable and supportive.
The clinic operated smoothly and was appreciated by most of the clients. Some of them participated in a client council which gave feedback to and made requests of management about any aspect of clinic operations. There was a climate of mutual respect between clients and agency management and staff.
Clients starting the methadone clinic were often using other drugs in addition to opiates, especially cocaine and / or benzodiazepines like Valium, Xanax, Ativan, and Klonopin. For most new clients, as the methadone dose was increased, the craving and dependence on other opiates and other illicit substances would decrease. Illicit use was monitored by regular urine toxicology screens which could distinguish between methadone, other opiates, and other substances. Dose increases and decreases were part of what was to be discussed in individual therapy sessions, with the clinician submitting requests to the director and to the medical staff, a consulting physician and administering nurses.
Methadone, an opiate, creates an addiction to methadone itself. But the opportunity to get a prescribed, clean and measured oral dose of this less intoxicating opiate is seen as reducing the harm caused by street drugs which were often taken intravenously, with possibly dirty needles, in unknown dose, perhaps financed through criminal activity and procured from criminals.
“Harm reduction” was the philosophy behind MMT, and “abstinence from all drugs” was redefined as “abstinence from illicit drugs”. “Recovery” was viewed as achieving abstinence from illicit drugs. Often people started at the clinic at a point in their lives where they were not fully committed to staying off all other illicit substances, but hopeful that methadone would help them to stabilize their lives. During my time at the clinic, very few clients were able to reduce their methadone use to zero and end their clinic involvement but many benefited from the clinic’s services.
Every morning, clients came to the clinic where a nurse administered their drink of methadone. Clients attended both group and individual therapy each week and could, over time, with sufficient program compliance, earn “take homes”, doses of methadone they could take home so that they did not have to come to the clinic every morning. As duration of compliance increased, they could achieve up to six days of take homes. Many clients achieved this, saving them from commuting to and spending time at the clinic.
Psychotherapy was mandated for all participants in the program. Some of my clients wanted our therapy conversations to help them stay clear of illicit drugs and for a few, to come off methadone itself. Others were not ready to stay off illicit drugs and wanted to use methadone as a supplement to what they were using illicitly. They were seeing me only because it was a condition of receiving methadone.
We had to assess their status and progress in the clinic which might take only a few minutes. Then, conversations with clients could be about anything including looking at relationships with family or employers, current upsets and opportunities, or any other life events. Some clients had a “dual diagnosis” meaning addiction plus one or more other DSM IV diagnosis, but this only figured in our conversation if it was useful to them.
Because psychotherapy was mandated, some of my agenda was potentially different from theirs. While we both understood that I represented society’s desire that they get clean, I found the “harm reduction” model a workable way to meet them “wherever they were”. Every client wanted to do less self-harm, if possible, and not too inconvenient.
The clients assigned to me in the CAB Methadone clinic ranged in age from eighteen to fifty five. My oldest client had been using opiates “since I was eleven”. He had been “on the clinic” and compliant with the program for many years, had been successful as a musician, still had ambitions, but had multiple other health problems. He had no interest in getting off methadone. He had many friends at the clinic and I was his “maybe about the tenth” clinician. He was on the client council and I felt like I was learning more from him than him from me. I was grateful for his patience in telling me how his world and the clinic worked.
Many Methadone clients attended twelve step programs like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), which they found to be helpful and supportive. Unfortunately, they sometimes encountered individuals in meetings who were not supportive due to those individuals’ belief that methadone constitutes “just another form of drug dependence.”
Another client was a young woman who was mandated to treatment because she was using opiates illicitly and was also pregnant. The court and Department of Social Services (DSS) sought to move her away from illicit use to MMT, which was seen as less potentially harmful or risky to her fetus. Her baby would be born addicted to Methadone but doctors have experience successfully weaning newborns from that addiction.
Her probation officer threatened her with jail if she did not comply with our program. Her attendance to our meetings was irregular; she was not that interested in the methadone program and she resented the demands of the authorities and the clinic’s tox screens the results of which were sent to DSS. She was not interested in talking with me, a position common for mandated clients and one that showed me the limits of both court mandates and my own good intentions.
Another of my clients, “Jimmy”, was a gainfully employed middle aged man who had been coming to the clinic for about ten years. He had been at the highest level of take home privileges for the last five, and he wanted to wean himself off methadone completely. Such attempts were not common, but I could see why he would like to be done with methadone and with the clinic, given the side effects of the methadone and the time and effort needed to fulfill the clinic requirements. Our routine was that he would ask me to decrease his dosage, and I then requested the agreed upon decrease from my supervisor and the medical staff.
In the months that he was my client, his daily dose of methadone had been 150 milligrams, average for many at the clinic. We slowly reduced his dose to fifty, forty, thirty, twenty, fifteen, twelve, ten, seven, five, three, and then to two milligrams. He had handled each reduction well, reporting at worst, minor symptoms which he was able to tolerate. I was fascinated with the process because I had another client who had asked me to reduce her dose from, 150 mg to 145 mg. She called me, distressed, reporting that the reduction was intolerable and she requested an immediate return back to 150 mg, which I fulfilled.
Clients could not tell how much methadone was actually in their daily dose because it was dissolved in an orange “drink”. Jimmy was so worried about eliminating the last two milligrams that several weeks passed without change. I suggested that he authorize me to request the reduction of the last two milligrams “sometime over the next month”, without telling him when it would occur. If he found himself suffering, he could request that his dose be restored, and I would comply. He agreed.
The next day, unbeknownst to him, I submitted the reduction request. For the rest of the month he received his daily doses of the orange drink and dutifully drank them, not knowing that they were just “juice without the juice”. At the end of the month, he inquired as to when I was going to submit the order, and was thrilled to learn that he had been “clean” for almost a month, with no ill effects.
From this man’s experience and from the individuals who claimed that they could detect a five milligram drop from one hundred fifty milligrams, I learned that much of what was called “addiction” was psychological. This is not to say that the psychological is not experienced as real; only that it is not necessarily biological or physiological. The man requested and was allowed by the program to continue therapy with me for the next several months and by the time I left the clinic he was still opiate free, leading a productive life, and attending meetings regularly.
The term “addict” has many different contexts and meanings. Like other diagnostic labels, the label itself can helpful for getting treatment but can also be harmful and limiting in societal and self regard. People labeled and self-labeled as addicts may not be able to explain why they cannot stop using opiates. Common reasons include chronic pain, relief from otherwise unbearable anxiety or despair, relief from other symptoms of trauma, and a need for the social community of other users. Methadone Maintenance serves to reduce self-harm and crime. As an institution and program that successfully administers methadone with ancillary services that include individual and group education and therapy, CAB MMT helps many people.
I worked at the CAB Methadone Clinic through the summer and left when school and my next internship started. I had spent a year at CAB including about eight months at the methadone clinic. I had encountered some well run programs, some chaotic programs, some clients using me and the programs to make changes in themselves and their lives, and some not.
By the end of my CAB tenure, I had gained a year’s experience as both an individual and a group therapist. I had some knowledge and first-hand experience of substance abuse treatment, and had seen that every client-therapist relationship is unique.