“We would like to take things to the next level with Raj. He seems to be ready and motivated, though he thinks he cannot make it. We would like to build on the momentum.” Edward articulated these words to Rodis, a consultant to the HOPE ACT team, working with Raj, particularly Maryann and Edward himself.
This is the fourth article of the series, New Strategies for Substance Use Assessment. In the first two articles, I outlined ten reasons why it is crucial to master and implement the New Strategies for Substance Use Assessment (for details, see the two articles entitled, New Strategies for Substance Use Assessment: 5 Reasons Why and 5 Additional Reasons Why of the New Strategies for Substance Use Assessment). In the third article entitled, New Strategies for Substance Use Assessment: 5 Questions to Ask, I described five key questions to help implement strategy, as part of a substance use assessment. In this current article, I am going to describe five additional questions you should ask.
“You have been learning and implementing the New Strategies for Substance Use Assessment, in your work with Raj, with good results. You now want to take things even further to the next level. Let us discuss the additional five questions that will help you do that,” Rodis reported to Edward and his colleagues.
The first five questions, described in the previous article, help with establishing rapport, with joining in, and with understanding and formulating a plan. Once you have reached this point, it is time to go to the next step that will prepare you to problem solve. This step involves having a clear picture of the magnitude of substance use, including the related consequences; assessing the stage of change for your patient and client; and discovering which barriers need to be overcome. Here are the five additional questions to ask when conducting a strategic substance use assessment, as part of this second phase.
1.Consequences of use
Some may be obvious and others may not be. Asking your patients and clients about consequences of use is a powerful tool, with an amazing ripple effect. It helps give you a better idea of the severity of the current use; it helps your patient and client sum up what he or she thinks the consequences of use are, and it also helps assess for the stage of change. “I had a good job with opportunities for promotion; I was in college for engineering, and I had a good girlfriend, Marla. I lost all of it. I have sought help, but I was always expected to “just be strong,” as if the picture of my mother being raped and killed in front of me, would just go away, just like that, by itself. I never had a chance to tell my story until now, but no one had bothered asking, anyway. I am tired of living like this. I want to stop using these drugs. They are not taking me anywhere good.” Raj expressed this to Maryann, with his head down and tears in his eyes. The answer to the question of consequences of use can help pave the way to getting to a commitment for change.
Some places provide substance use treatment and neglect the associated mental health and other general medical conditions. Other places treat the general medical or mental health conditions and neglect the associated substance use disorder.
As stated in the first two articles of this series, we have been practicing healthcare in a silo, practicing fragmented care, and this has been to the detriment of our patients and clients. It has also been of harm to us, as clinicians, to our agencies, and to the health system, as a whole. Asking about comorbidities helps us circle back to one of the previous questions regarding the explanatory model of use for our patients and clients.
“I saw my mom being raped and killed in front of me, and I could not save her. I have always hated myself for that and when those pictures come back in my head, I just cannot take it,” stated Raj, in response to the opportunity given to him to state his explanations and reasons for substance use. While Raj did not say, “I had untreated PTSD as a comorbid disorder,” the description of his pain vividly presents PTSD for consideration. “I have difficulty sleeping. I wake up in the middle of the night, screaming, trying to wake up my mom, lying on the floor, in the woods. I also had two small heart attacks and the doctors told me they are from cocaine.” Caring for the patient and client with substance use disorder is no small task. It is no wonder that so many of us develop such strong countertransference and biases against them. But it does not need to be this way. With the mastery and implementation of the New Strategies for Substance Use Assessment, you will have the required tools for making a difference in the lives of your patients and clients.
3.Sense of self
As I once described in a previous article entitled, 5 Tips to Help Engage Your Patients and Clients, Jay, a 21-year-old male, after six months of remission from Opiate Use Disorder, told me, "Now that I don't use, and I don't hang out with my old friends, I don't know who I am anymore. I don't feel like I belong anywhere, because all I knew was being an addict, since using when I was age 14."
Asking our patients and clients about their sense of self helps us identify, early enough, barriers to treatment, to sustained sobriety and ways to prevent relapse. “I don’t really think I can. I don’t think I can make it. I want to stop, but I honestly don’t see how this will be possible,” said Raj, when asked how he felt about himself.
Take some time to ask your patients and clients about their sense of self. And, when you hear something like Raj’s response, make sure to prioritize restoring a sense of self in the treatment plan. For many, other interventions may be to no avail unless you help restore their sense of self.
4.Stage of change
Stage of change is related to sense of self in that it helps you meet your patients and clients where they are at. The answers to the question regarding consequences of use can also give some hints to the response to the question related to stage of change. Furthermore, asking your patients and clients about this requires a combination of art and soft skills.
“I had a good job with opportunities for promotion; I was in college for engineering and I had a good girlfriend, Marla. I lost all of it,” said Raj. With this answer, instead of a follow up question, a validating or reflective statement like, “You seem to be saying that there have been some consequences and some problems related to your use, and something needs to change.”
This implies that Raj is beyond Pre-contemplation, the first stage of change. However, during exploration of his sense of self, Raj also said, “I want to stop, but I honestly don’t see how this is going to be possible.” Once again, instead of a question, a statement like, “You believe there is a problem but you do not think there is a solution.” With this, Raj would belong to the Contemplation phase and short of the Preparation phase, not because he is not ready to change, but, rather, because he does not think he can change. This knowledge will help the team focus first on restoring his sense of self.
5.Purpose and meaning
In a previous article, entitled, In Search of A Purpose, I stated that, according to the Cambridge English Dictionary, “Purpose” is defined as the reason for doing something or for allowing something to happen; and that living life with purpose means making the conscious decision to understand your life, to consciously evaluate the “why” of your life and deliberately live and strive towards it. In that article, I also explained that if you currently feel like you have no clear purpose or have lost it, or stopped living it, then, at best, you may experience an unhappy life with little meaning, and at the worst, you will likely experience a constant, incessant and insatiable pursuit of happiness. This could unfortunately lead to addictive behaviors and to an increase in physical illness, mental illness, and even suicide. The loss of purpose may take place after a major loss, a crucial setback, or a traumatic event, as in Raj’s case.
Also, I continued on and discussed some of the benefits of living life with purpose. I described that a life with purpose helps keep vision in mind; it sets your destination path, which in turn keeps you motivated and makes it easier for you to withstand life challenges. I added, too, that living life with purpose also forces you to become more self-aware, to be more deliberate, and to make more conscious decisions. I cautioned that this might sound challenging, difficult, and even impossible, at times. Where it may sound onerous, and it can be, it is also doable, and the process of getting there is an important part of self-discovery.
By the time you have finished reading these two last paragraphs, you might be wondering, not less than one time, what does purpose, or meaning, or life with purpose, have to do with new strategies for substance use assessment?
Let me explain. While the rate of substance use disorder is higher in physicians than in the general population (10-15% versus 6-9%, respectively), the recovery rate is higher compared to any other group (at least 80% and much higher in other studies). The question is why such a high recovery rate among physicians? One of the most recurring themes is purpose and meaning.
The next time you meet with your patient and client affected by substance use disorder, ask him or her, “what gives you purpose, and what gives you meaning?” Whether your patients and clients know the answers or not, you can work with them on either finding or restoring their purpose. The two articles entitled, In Search of A Purpose and Finding Your Passion include guides you can use to work with your patients and clients.
“I tried to kill myself several times and I am still alive. I believe I am here for a reason. I don’t really know why, but I would like to know,” responded Raj to the question regarding his purpose. Edward, Maryann, and the rest of the team are taking steps to start working with Raj on finding his purpose and passion, while connecting it with his sense of self, harm reduction, and treatment for his symptoms of trauma.
Maryann and her team started by not knowing what to do with Raj. After consultation with Rodis, they have came to realize what they did not know and made the decision to learn the New Strategies for Substance Use Assessment and implement them. Now, they have been seeing good results.
My hope is that you use the fundamental principles outlined in these four articles, implement them, and look for additional resources to continue to provide excellent care to your patients and clients. Thank you for continuing to share your experiences and for allowing me on this noble journey with you. Until soon.
Your friend and colleague,
For more in this series of articles, check below!
Dr. Sidor is quadruple board certified in psychiatry, with board certification in General adult, Child and adolescent, Addiction, and Forensic, psychiatry. He also has additional training in public psychiatry, in several treatment modalities, in addition to his teaching, supervision, mentorship, and management, experience. Some of his passions are public speaking, leadership, business, and research, in addition to program development and project management. His overall goal is to empower all health care professionals throughout the United States and globally, towards ensuring the continuity of excellent patient care, while balancing the need to take care of themselves. Dr. Sidor is the main instructor for the SWEET Institute, and he is currently an Assistant Professor of Psychiatry at Columbia University. He is also the past-Medical Director for CASES (Center for Alternative Sentencing and employment Services), and he speaks and writes fluently in six (4) languages—French, English, Spanish, Creole, and has intermediate proficiency in Portuguese and Italian.
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