November/December 2012 Issue

Treating Professionals With Substance Use Disorders
By Lindsey Getz
Social Work Today
Vol. 12 No. 6 P. 14

Treatment requires dedicated therapeutic settings and providers trained to encourage patients to relinquish their caregiving roles and receive help themselves.

When it comes to substance use and abuse, members of the helping professions, such as social workers, psychologists, doctors, and nurses, are at as great a risk—if not greater—than the rest of the population. With high-stress jobs and burnout always a possibility, some may turn to drugs or alcohol to keep going or to relax. But when addiction takes hold, there is no easy escape, and professionals battling the disease may have even greater obstacles to hurdle.

The Social Work Dictionary defines an impaired social worker as “one who is unable to function adequately as a professional social worker and provide competent care to clients as a result of a physical or mental disorder or personal problems, or the ability or desire to adhere to the code of ethics of the profession. These problems most commonly include alcoholism, substance abuse, mental illness, burnout, stress, and relationship problems.”

Throughout his career, Frederic G. Reamer, PhD, a prominent ethicist and professor of social work at Rhode Island College, has worked with numerous professionals he would consider impaired but, on average, says this is a small percentage of the social work population. “The good news is that we’re getting much better at addressing these issues,” he says. “The incidence hasn’t increased, but the awareness of impairment risks has. There is a greater willingness to acknowledge and address these issues.”

Substance Use and Abuse
A focus on professionals with substance use disorders reveals that there are some specific challenges for this population. For one, research suggests that professionals such as social workers may be reluctant to seek help for addiction. In fact, a study published in Social Work found that social workers do not frequently seek help, even when they are high-risk alcohol and drug users (Siebert, 2005).

Those in the treatment field surmise that professionals’ reluctance to seek treatment may be linked to their personal beliefs about who they are and what they should be capable of doing. Helping professionals may struggle with a greater sense of guilt and shame than the rest of the addicted population. “They feel they should be able to control their drug or alcohol use,” says Tina Black, LCSW, clinical services director at Talbott Recovery in the Atlanta area. “There’s a lot of self-judgment, and people in those positions can struggle with a greater degree of shame because of their role as caregivers.”

“There is an internal voice among professionals that tells them ‘I’m competent. I’m successful. Therefore, because I have an issue with a substance, it must mean I’m a failure,’” adds Dean Fitch, LMFT, LCDC, director of counseling services for Starlite Recovery Center in Center Point, TX. “Often these individuals are so high functioning and assume they can handle themselves—or are too ashamed to admit they can’t—that it gets really bad before they get help.”

Reamer points out that the literature, as well as his own experience, points to the fact that impairment taking the form of substance abuse is typically a subset of a broader class of issues. “I have had cases where a practitioner is struggling, and the struggle is from multiple sources—marital issues, an issue with a child, or stress at the workplace,” he says. “It’s not unusual for the substance use and abuse to be just one facet of a number of sources that are causing impairment. These problems don’t occur in isolation, so it’s important that any treatment module is addressing the entire problem.”

Tackling Treatment
There are several approaches when it comes to the best treatment protocol for professionals with substance use disorders. Many lean toward a 30-, 60-, or 90-day residential program, and some state licensing boards require that.

Chris McCoy, LMSW, CAC-II, a recovery specialist with the Recovering Professional Program in Cayce, South Carolina, works with several licensing boards to meet their specific requirements and says they can vary greatly based on the profession. Many of the patients at the Recovering Professional Program did not voluntarily refer themselves to the program. McCoy says the program’s emphasis is on total abstinence and learning chemical free coping skills.

At Talbott Recovery Campus, the residence provides a “lab-type” environment for patients to practice newly learned coping skills to manage challenging situations without using drugs and alcohol. It’s some real-life experience in the safe haven of the facility confines. “Patients are in small groups all day long,” Black says. “They usually range from 10 to 12 people. Addiction is a disease that involves mood altering, so many patients struggle learning to experience the normal range of emotions without drugs or alcohol. Being in a small group helps them work on that.”

At the Methodist Richardson Medical Center’s Impaired Professional Recovery Program in Dallas, a 30-session outpatient program is tailored to the patient. Bob Good, LCDC, says that in comparing the disease-specific and sobriety maintenance content of 30-, 60-, and 90-day residential programs, he believes that the 90 hours (three hours per day on three days per week) patients spend in his program is potentially more intense. It’s a cognitive therapy-based program focusing on education-based skills training.

“We deal with a population that is highly educated and usually well into their careers,” Good says. “Therefore, we do very little process therapy and really focus on cognitive restructuring. Those needing process therapy are secured an outpatient therapist, and those needing medication management are secured an outpatient addictionologist. A lot of people will say that they feel so comfortable in the program because it feels like they’re back in school.”

Fitch agrees that using a patient’s higher level of intelligence in the treatment module can be a successful tool. “These are intelligent, high-functioning patients, and they often want to intellectualize their treatment and get more involved in understanding it,” Fitch says. “Embracing that may help facilitate recovery for this population.”

This higher level of understanding also can be used to help educate a patient on the disease of addiction. Even a large part of the medical community has a hard time grasping that addiction is a chronic progressive disease and not just an issue of morals or will. “We have physicians who do not realize that it is a chronic organic brain disease, so they don’t understand why they can’t stop,” Good says. “Getting through the education is really an important step. Then comes acceptance and ultimately acknowledgement on the path to recovery.”

“There is a vast degree of education required for people to understand addiction,” Black adds. “Even after receiving a medical explanation of the disease and viewing scans of the brain that show the disease progression, patients will still struggle with acceptance of addiction as a disease and [experience] guilt and shame, feeling that they should be able to control their drug and alcohol use. We try to remind patients that everything is a process and it takes time to achieve acceptance.”

Extra Attention on the Healthcare Professional
The length of stay in residential programs and the overall duration of treatment may vary by patient and profession, but there is a strong argument that healthcare professionals need extra attention, no matter what the program. For instance, the residential treatment program at Hazelden in Center City, MN, lasts an average of 28 days for the general population, but for healthcare professionals, it’s generally 60 to 90 days.

Marc Myer, MD, director of the healthcare professionals program at Hazelden, says the reason for the longer length of treatment for healthcare professionals is typically because treatment for this group is more complicated. For example, the likelihood of a healthcare professional having a comorbid psychiatric illness is higher. A recent study published in Addictive Disorders & Their Treatment found that more than two-thirds of healthcare professionals with a substance use disorder reported a comorbid psychiatric disorder with major depression accounting for approximately 40% of these cases and 58% reporting the use of psychiatric medication (Rojas, Brand, Fareed, & Koos, 2012).

Most professionals in treatment have concerns that the general population may not worry about—namely legal and medical concerns. “Both the patient and their employers may have some serious concerns,” Myer says. “So the reason for a healthcare professional’s longer stay may be driven by the literature that shows excellent outcomes in a cohort scenario. We find it extremely important for them to be part of a cohort so that they’re interacting with other addicted healthcare professionals and talking about issues that are specific to them such as work-related stress, high rates of burnout, and being in the caregiver role. It’s not uncommon to neglect self-care when in a caregiving role.”

“It’s very powerful for caregivers to be among their peers while in treatment because of the guilt and shame issue,” Black adds. “Group work is most effective in addressing these issues of shame. Professionals can see that there are other social workers or healthcare professionals struggling with the same issues.”

Additional Complications in Treatment
Treating a professional with a substance use disorder may pose specific challenges. “There are certainly some unique features of being a social worker that can exacerbate impairment, which you wouldn’t find in other professions,” Reamer says. “We know that clinical social workers, for instance, spend their entire days helping people by listening and giving, giving, giving. And those relationships are not reciprocal—that’s the nature of the design. But when you’re treating that practitioner, it’s important to recognize that for that person, it may be extraordinarily difficult to be the client when they’ve spent their entire career in the driver seat.”

In fact, all of Social Work Today’s expert sources report that one of the biggest challenges that can arise when working with helping professionals is their own difficulty in taking on the patient role. Black says therapists coming in for treatment normally struggle making the transition from care provider to patient since therapy is a mode of treatment for addiction.

“Helping patients who are used to providing therapy accept that they have to be on the receiving end of therapy is certainly a challenging obstacle in providing treatment,” Black says. “In fact, as a facility with a residential component that also treats comorbid psychiatric illnesses, we find that recovering therapists struggle to take off that ‘therapist hat’ among other residents.”

At Starlite, Shannon Malish, LMSW, adult program coordinator, says this is a natural tendency for those in the helping professions. “We have to set real clear boundaries in the beginning because those in the helping professions have a natural instinct to help,” she says. “While they may start wanting to help other patients, they have to recognize that they’re the ones that need help at this point. They may want to help their roommate, but they have to remember that could be how they got there in the first place—by getting burned out by helping others.”

Fitch adds that coming into a treatment facility for professionals and then throwing oneself into a helping role also may be a way of coping or keeping busy rather than accepting the need for treatment.

“We try to use that as an opportunity for therapeutic reflection,” Fitch says. “We may emphasize that their assignment is to not give anyone advice. That will allow them to gain some insight and deal with who they are as a person rather than focusing on everyone else. We can become so defined by our professional roles that we forget who we, ourselves, are.”

Recovery and the Future
Relapse is a possibility with any addicted population, and whether professionals are more or less likely to relapse is a point of contention. McCoy says there is a silver lining to the idea that healthcare professionals make difficult patients: their internal motivation to maintain licensure and successfully complete the program—and maintain that lifestyle—can be quite compelling. He says the physicians served through the program often are the most successful given their drive.

Malish says these professionals often want to grab the bull by the horns and go full throttle into recovery. But she’s also seen professionals who really struggle to recover. “I think with these types of professionals, there is a higher level of intellectualizing that they can ‘get through this’ and maybe they think they don’t need to continue with meetings,” Malish says. “Like the general population, it often starts with ‘just one’ [drink or drug] that they think they can handle and then they’re back in treatment again.”

Black says it’s important to talk to the patient’s family about the possibility of relapse, or “return to use,” which is becoming the preferred terminology.

“Not everyone returns to using, but many do have episodes of return to use, and it’s important to explain this to the family because it’s an area where they can pay attention and help,” Black says. “There is an element of dishonesty that comes with addiction and most patients, particularly professionals who also carry that heavy degree of guilt and shame, will hide their return to substance use. But with a strong support system, patients can overcome this and eventually find themselves maintaining a healthy lifestyle.”

— Lindsey Getz is a freelance writer based in Royersford, PA, and a frequent contributor to Social Work Today.

What Does the Code of Ethics Say?
The first Code of Ethics was ratified and adopted by the National Association of Social Workers (NASW) in 1960 and at that time, there was no mention of issues of impairment. When a second code was drafted in 1979, it still failed to address the issue. In fact, it wasn’t until 1994 that the issue of impairment was addressed.

Frederic Reamer, PhD, a professor of social work at Rhode Island College, was asked to chair a task force to explore the drafting of these standards. Reamer had long been advocating for the code to alert social workers of their ethical responsibility to address colleagues that appear to be impaired. “The fact that our Code of Ethics now explicitly acknowledges the issue of impairment is incredibly significant,” he says. “However, the bigger challenge is actually implementing those standards and helping social workers to take concerns about themselves and their peers, seriously.”

Reamer sees the solution in continuing education. “A lot of states now require ethics education in order to renew one’s license,” he says. “That is a good step. While I think we’ve done a great job establishing reasonable and fair ethical standards, I do believe we have a long way to go in education and training. Ultimately, I’d like to see more social workers paying attention to the possibility of impaired peers or even their own potential impairment.”

— LG

References
Roja, J. I., Brand, M., Fareed, S., & Koos, E. (2012). Psychiatric comorbidity in health care professionals with substance use disorders. Addictive Disorders & Their Treatment, epub ahead of print.

Siebert, D. C. (2005). Help seeking for AOD misuse among social workers: Patterns, barriers, and implications. Social Work, 50(1), 65-75.