I don’t believe you: Denial, Details, and Goal Setting

Sometimes a client will be so insistent that they don’t use a substance, or that its use is not a problem, that the counselor might find themselves questioning reality. Today we call this the “precontemplation” stage of change, but we used to call it “denial,” and whether it’s an actual belief that nothing is wrong or a systematic telling of untruths aimed at prolonging drug use, the effects on the client can be the same: A worsening of the problem, increasing dysfunction across life domains, and possibly death.

Even when there is evidence to the contrary a good counselor might begin to question what’s actually true, because the client is so consistent in making the same statements that it becomes like a mantra for the both of you. The client might even have other people in other areas of their life legitimately fooled (e.g., family members, a doctor, a caseworker), and this may be the product of them neatly compartmentalizing information and feeding specific bits to different people based on their “need to know.” As a counselor, part of my job is to pay attention to the signs of the disorder that bubble to the surface and are difficult for the client to dispute – at the end of the day, track marks don’t lie, and most of the time neither do laboratory tests.

Such was the case of X, previously mentioned in “A Captive Audience and SUD Criteria.” X had come in for a screening and initially not met criteria based on their fragmented disclosures. After a couple of days, I learned they had tested positive specifically for heroin (not just a generalized opiates result), and then later for heroin and cocaine, and I scheduled a follow-up. During the follow-up they flat out denied cocaine use, and claimed the heroin positive was a result of buprenorphine/naloxone (used to treat pain, but also commonly heroin dependence). Of course X had been saying this left and right to everyone at home, and her family was convinced it was true. Somehow, X had even managed to a psychiatrist testify they were positive for heroin because of past use, and the heroin was in their DNA even if they weren’t actively using.

Imagine that! Unbelievable, I know. But, even in the most outlandish of rationalizations, a counselor who’s paying attention can find something with which to start chipping away at the wall of denial. In this case, it was the “expert” testimony of a psychiatrist that X had used heroin in the past and now it was “in their DNA,” and they were doomed to forever test positive. Once I pointed out the previous use, X‘s flat denials turned to a limited admission of former use, and that then evolved into something like, “I had a slip-up last year before I knew the condition I was in.”

So there I am, pointing out to X the discrepancies, but still X says in exasperation, “Why do you keep asking if there’s a problem?! I don’t have a problem! It was just a slip-up, and what I do with my body’s my business!” So X just won’t admit that there’s a problem even though they’re on medication for the problem, they tested positive for the problem in the hospital, they returned positive for the problem and cocaine in subsequent tests, and the track marks covering both arms look like a pretty serious problem.

At this point I felt like throwing my arms up in frustration, but decided to follow the advice of my sage agency director: Respectfully, let the client know you don’t believe them and that’s okay, because you can agree to disagree. And it worked! Here’s more or less how that conversation went:

Me: Look X, I know you’re telling me you don’t have a problem, but I’m not going to change my diagnosis because I have to go based on the evidence I have available, and that all points to you continuing to use heroin. Now, I’m not asking you to agree with me – I’m just asking you to understand where I’m coming from. And I don’t have to agree with you either – I understand you’re telling me there’s not a problem and that’s okay. But I’m not going to change my mind, and you’re not going to change your mind, so it’s okay if we disagree and let’s just move on instead of going in circles. So, what’s your goal?

X: To get my CPS case closed.

Me: And what can you do to make that happen?

X: Keep coming here and test negative.

I don’t know if it’s difficult to believe or not, but X actually smiled during that exchange and seemed to take this well. And there it was – a maneuver around denial and the beginnings of a workable treatment plan with a perfectly acceptable goal and objective. It may have been nicer if X‘s goal was to stop using heroin forever, but to get out of treatment successfully is a good start, because in order for that to happen the client needs to demonstrate abstinence. I’ll take that any day.

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