It takes a caring heart and a willing spirit to sit across from patients for hours each day while they divulge their greatest concerns, fears, and unresolved trauma in front of you. This is not a profession that tire-kickers and the unhealed should seek. This isn't a profession that people should be in just because it provides a paycheck. Patients deserve better than that. Patients deserve a caring professional who is honest, selfless, empathetic, properly educated, understands human psychology as well as addiction science, is personable, and is truly invested in helping them heal. Being a nice person with a great measure of patience and understanding is also valuable. In fact, you can't do the job well without possessing those virtues.
We're not that different from our patients, we just made different choices
I do this job with reverence and humility, because I realize that I too could have found myself in the same situation as my patients had I made one or two different decisions with my life. The stigma that our patients have to endure—that they're all just criminals and generally unintelligent, bad people—is something that I vehemently reject. The overwhelming majority of the patients I have met are good, intelligent people who've just had very tough lives. And while there is a good measure of patients in this population who have fallen into criminal activity, it's frequently a symptom of addiction; it's not the people they truly are. As addiction professionals, we have to do all that we can to help patients get back in touch with the people they were before they began abusing drugs—People who may have led normal lives, held steady jobs and careers, had families, and had dreams they were actively pursuing. Each person had a life they were in control of before substance abuse. That person is still in there, they're just being held captive by their addiction.
Technique is great, relationship is best
MI, CBT, DBT, ABC, XYZ... all of the therapy acronyms are great, proven techniques to use in order to help patients overcome addiction, and we absolutely should use them. But the bottom line is that none of it will make a difference if your patients don't like you and you're unable to build a relationship with them.
I've worked alongside counselors who had a lot more experience than me, and a lot more formal mental health education than I had. Yet, I watched them struggle mightily to help their patients stop abusing substances. During case conferences, they would present patient after patient that just continued to use week after week with little or no improvement. They would present case notes with elaborate therapy techniques and terminology sprinkled throughout. It was clear that the counselors were trying very hard with the therapeutic science, but they were neglecting the relationship aspect. That's why—by and large—their patient's weren't improving.
There have been times when I've had sessions with some of those counselor's patients (the patient's regular counselor would be out sick or on vacation), and by the end of the session the patient would be asking to switch to my schedule and start seeing me. This, unfortunately, has happened quite a bit. Believe me, I made zero effort to poach the patients of other counselors. My schedule has always been packed to the point that the last thing I've wanted or needed to do was increase my caseload. But the patients who wanted to switch to me would often tell me that I was the first counselor who really listened to them, seemed to actually care about their lives, and helped them find real solutions. They could see the genuine attempt at relationship building I was providing that may have been lacking with their regular counselors.
I guess my "secret weapon" isn't much of a secret to the patients. I do really listen to them, I do actually care about their lives, and I do help them find real solutions because I want to see them win.
Relationship, relationship, RELATIONSHIP
Counseling isn't just a set of techniques and parameters. It's not just about crafting a bunch of treatment plans and repeating therapy terminology. It's certainly much more than paperwork. When patients attend their appointments, the majority expect to build a relationship with their counselors. The goal of the counselor should be to create an environment that makes the therapeutic alliance possible.
I've found that many patients are struggling in life due in large part to a lack of stable relationships. For many patients, without therapy, they have no one to share their successes and failures with. No one to bounce ideas off of. No one to talk to about job, family, and romantic relationship matters. And even worse, no one to discuss their addiction with. So, they continue turning to drugs and alcohol as a way to cope, perpetuating a vicious and destructive cycle.
When a counselor comes into the picture, they can either establish themselves as yet another superficial character in their patient's lives and see their patients have little success. Or, the counselor can become the one person the patient can count on—showing a true desire to see them succeed, and watching as success becomes their expectation rather than an empty wish that is far out of reach.
So, how do you build relationships with patients?
When a counselor actually cares, it's not very complicated at all. I look at it through this basic framework:
- Genuinely care about the patients and their lives
- Remember the conversations you've had with your patients and draw from them
Patients appreciate that you're paying attention and remembering what they say. It shows them that you have an interest in them, and you see them as the important and valuable people they are.
- Follow up with the patients on the events of their lives and their goals
- Focus on the details of the patients lives and what is important to them in each and every session
- Do what is best and ethical for the patients, with their consent, at all times
With all of that in mind, I open nearly every session with this simple but important question, "So tell me what's been going on with your life since the last time we met."
Don't look at this as just a checklist of things to do. You're not using this as a mere means to an end. That would be the wrong approach and mindset entirely. Instead, you need to want to do this. You need to sincerely care about your patients lives in order for this to work. If you really feel that, your patients will feel it, too.
How do you know when it's "working"?
You know that your effort to build a relationship with a patient is working when:
- Your patient shows up to their appointments consistently, or when their attendance goes from sporadic to consistent
- Your patient is open and willing to talk to you about any aspect of their personal lives
- Toxicology results begin regularly trending in the negative direction
We need to zero-in on that last point.
When you've built a strong professional relationship with a patient, it may become a situation where they refrain from drugs and alcohol not simply because they want to stop using. On the contrary, sometimes, they refrain because they greatly value you and the relationship you've built together. They can reach a point of feeling that by using drugs and/or alcohol it will fracture the relationship, and they don't want to disappoint *you.*
If you ever sense that with a patient, you need to let them know that no matter what they do, you are proud of them for refusing to give up and continuing to come back to treatment. It may or may not change their orientation on this, but it will let them know that you are there for them with unconditional positive regard.
Nevertheless, any circumstance in which a patient is not abusing substances is favorable. In this day and age where street drugs are frequently laced with extremely dangerous additives like fentanyl, nitazenes, and xylazine, a patient's sobriety is literally a matter of life and death.
In the end...
At the core of being an effective Substance Use Disorder Counselor is building real therapeutic relationships with patients. These relationships should always operate with safe, ethical, professional boundaries in place. Therapy techniques are essential, but building relationships is at the center of it all. It's the foundation. Without it, your patients will never see you as more than just another person doing a job for a paycheck, and success rates will be limited.
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In a future piece, we'll discuss the potential pitfalls of building strong relationships with patients, and the clinical boundaries that counselors need to set in order to maintain healthy therapeutic alliances.