Case Example – Substance Disorders

Having been privileged to work with thousands of addicts over the course of my career, I have seen my share of successes and devastation. In presenting these cases, all identifying information has been removed and all names of people and places altered to assure anonymity. I present these cases not as a means to sensationalize this disorder but to show the extremes of impact that addiction can have and the joys that are experienced through recovery.

John came to see me post inpatient treatment for a problem with Percocet. When we first met, he was very angry with the medical profession and he was holding them, more specifically his family physician, solely accountable for his disorder. Upon meeting John he presented very positively from a physical aspect, was well spoken, and cooperative. John entered treatment after he was discharged from a local hospital for severe withdrawal treatment. Apparently, John had experienced a back trauma in his work and sought medical attention from his family MD. His MD placed him on a short-term disability immediately and prescribed a dose of Percocet (oxycodone and acetaminophen) to address his pain issues. Through diagnostic testing, it was determined that the back trauma was muscular and not structural. It was suggested that he seek a course of physiotherapy to remediate the problem. John attended the physiotherapy but continued to complain of back pain to his MD. He later admitted that he continued these complaints as a means to obtaining more Percocet as John discovered that taking Percocet also allowed him to ignore other issues within his life. Over time, John’s MD had increased his intake levels to 70 Percocet per day or 350mg of oxycodone—this is a significant amount of narcotic but clearly shows the bodies ability for the development of tolerance levels. Of additional concern was the amount of acetaminophen being ingested and thus processed by the liver. Percocet is a highly addictive narcotic with an elevated tolerance cycle. It is a medication to be used with caution and constant monitoring…in John’s case neither of these conditions existed. John might have continued this addictive cycle had it not been for a business trip. Somehow, John did not fully think through the amount of prescription he would require while away and as a consequence ended up running out of his Percocet! Percocet is not a medication you want to run out of especially at the levels that John was taking. This drug has a short life within the body, which means withdrawal effects will begin soon after the last dose. Within six hours of not having his Percocet John began to experience higher levels of pain, was sweating profusely, and was very agitated. Within the first 24 hours after his last dose, John experienced a cardiac event as a result of his withdrawal–it was this event that placed him in the hospital and later into inpatient treatment.

As I stated, by the time John came to me he was very angry with his doctor and blamed him for the addiction. Not that the doctor wasn’t at fault for part of this occurrence, however it needed to become clear to John that it was his lying and deceit that led to the elevated prescribing. His doctor was simply responding to someone with pain management issues…however, upon further exploration the doctor might not have taken this route with John. As therapy evolved John was able to see his part in developing and maintaining this disorder, had accepted the need to remain abstinent, and was active in Narcotics Anonymous. Nevertheless, I jump ahead…how did he get here in the first place?

John came from a dysfunctional family system (like all of us) that was scattered with alcoholics. Because of this, he had sworn to himself that this would never happen to him; albeit that he would drink now and then, his use was not in a dependent class when we met. He was abusing alcohol now and then and also found that it became a precursor to his elevated Percocet usage. Upon taking Percocet for the first time, he felt an overwhelming sense of relaxation and release from his stresses, which he enjoyed. Over time and due to tolerance rationales he had to continue to increase the dosage to chase that same effect. On a few occasions, he feared of overdose but was afraid to seek medical attention because he knew he would lose his prescription. He began to lie to his physician about his pain levels and make claims that the physiotherapy was causing more pain to justify the increased prescription amounts. As his Percocet intake increased, he also began to isolate from others for fear they would discover what he was doing. John began to discover what every addict finds out—you can chase that original high forever but you‘d never find it again. It was only by “mistake” that John ended up stopping, had he not had a cardiac event he might still be using today or worse…he may have eventually overdosed. In a strange way, he remains forever grateful for that trip that sent him into withdrawals.



More and more it appears we exist in a society where people prefer to blame, deflect, and avoid rather than be accountable. Addicts living within their disease are masterful at blame, deflection, and avoidance—it is part of the behavioral makeup of the addict and part of the reason so many in the helping professions dislike working with this population group. I think that part of the disdain comes from the structure of the counseling relationship which is often predicated upon accountability and insight and the addict does not play “good patient” thus the “expectations” within the clinician are not met. Part of the reason I enjoy working with addicts is because of these traits; albeit that many of the stories become similar over the years there is always that one addict that has a new twist on blame, deflection, or avoidance and their story is intriguing in its presentation. I have learned many a lesson from working with addicts– one of which is that perception truly is reality. Addicts live in these “lies” for so long that they often come to believe it as truth, so the work begins around changing perceptual lenses. I “expect” the addict to display these traits and thus the process is normalized through this dance rather than frustrating. It is through their blame, deflection, and avoidance that the truth can be sought and accountability specific to their world can be brought forward. I become more concerned with the addict that accepts accountability right from the outset as this is atypical and may be an indicator of someone who is not fully committed to the process–it becomes his or her form of avoidance in a paradoxical manner.

True accountability comes when the addict understands and accepts that their disorder was not caused by family, work, friends, traumas, relationships, losses, religious denominations, etc. These factors influence, accelerate, and exasperate an addiction, but they do not as a stand-alone cause an addiction. Substance dependence for many is created from a genetic predisposition to addiction with psychological, social/environmental/developmental, and spiritual issues. There is a vast body of research related to the genetic predisposing factors related to substance disorders and most in the field are in agreement that addiction is a bio-psycho-social-spiritual disorder; meaning that these pieces need to come together in a manner whereby addiction is the result. It is important to note that a genetic predisposition alone is not a life-script for dependency. I have met many individuals that have come from families where addiction was rampant but that they themselves did not develop dependence—the reason…all of the other areas did not line up. They have a familial history for addiction yet they were raised in healthy environments, developed good peer relations, and held a strong spiritual grounding that when combined kept them from a life of addiction.

So accountability is a process of seeing where the addict played a role in this process; this is not to say that it is only because of poor decision making that one becomes addicted and that addicts are characterlogically flawed people (as this is simply untrue of most). What I am saying is that the addict needs to perceptually refocus the lenses so they can see their part in the process as this is the only part they can change and if they take this action, they begin to alter the behavioral aspects to this disease.

A good example of this perceptual reality is that many addicts hold the belief that everyone in the world uses substances–maybe not the same way that they do, but nonetheless everyone uses. Until they see that this is untrue, they cannot believe that abstinence is even possible.


Becoming Accountable – Exercise

To begin the process of Taking Accountability for an addiction there are some specific and concrete methods in getting there. An individual can begin by writing a complete “Personal Use History” through documenting impact statements for each age range and each major life area (MLA). MLA’s include family, friends, work /school, financial, legal, physical, psychological/emotional, and spiritual.

Appropriate age-range parameters could include 10-16, 17-20, 21-30, 31-40, 41-50, 51-60, and 61-70. As such, you would have a statement for every age range as it relates to every MLA. This exercise will produce a very clear impact analysis, which permits an individual to see this disorder in its entirety versus small “justifiable” events.

A relationship with substance use may go back a long time. Learning how substances fit into someone’s life can help. In addition to a “Personal Use History”, an individual can take time to write about their answers to the following:

1. What do you notice about how substance use affects you?
2. What will it take you to learn to live without substances?
3. How much is substance use a part of your family and lifestyle?
4. How often do you use substances to celebrate?
5. How often do you use substances to cope with negative feelings?
6. How often do you use substances to provide a sense of belonging (e.g. in a social gathering)?
7. When did you begin using? What did it mean to you then? What does it mean to you now?
8. How could stopping substances change your work performance or work patterns?
9. If you stopped, what things would you have that you do not have now?
10. How do you think you would feel if you were not depending on substances?
11. What relationships might you have or might you improve if you were not using?

Answers to these questions and others engage an addict in a manner that is unfamiliar to most— seeing the totality of their behavior and actions. Addicts are very good at rationalizing and justifying events as one-offs; it is when they explore the whole picture that this exercise in rationalization becomes extremely difficult to perform.


Accountability – Case Example

John came to see me after a referral from his workplace. While assessing John, it became clear that he was over-complaint to this process for someone who was attending an assessment under duress. However this behavioral stance became clearer as our time together passed; he had believed that there would be no other diagnosis then someone who had made “one bad” decision and thus clearly non-dependent. He additionally believed that he could convince me of this belief and that we would spend a pleasant two-hours together. However, things altered at about the 1.5-hour mark when it was clear that this man was experiencing a full-blown dependency disorder that would require intensive treatment. At this point, he became agitated and stated that he would launch a full formal complaint with both his company and my professional association regarding such egregious conduct on my part. In exploring options within his company, he discovered that the assessment recommendations would stand and that he was provided with an option to follow these or seek other employment. To say the least he was appalled at the company’s decision in not providing greater support to one of their most senior employees.

Regardless of his disdain for the process, John contacted an inpatient treatment facility and began the process of following the recommendations as identified in the assessment process. When he entered treatment, he was very clear with the staff that he was there against his better judgment but was required to complete this for his employer; this stance was met with an immediate discharge, as the treatment facility will not admit people who do not believe they have a problem. John was now in a bit of a conundrum as he needed treatment to keep his job yet he had already told the treatment team that he did not believe he had a problem and he had further complained about my professionalism to anyone who was within ear shot for over a week (this information always has a funny way of making it back). Now backed into a corner, he called my office to see if he could have another appointment–which was immediately granted. He was surprised that I was willing to see him again after his original conduct. I informed him that I had seen this type of reaction many times over the course of my career and did not take it personal in any manner.

His first focus in the session was on the unprofessional conduct of the treatment team that discharged him and how they needed to be “as understanding as I was”. John was again under the belief that his smooth talking complimentary behaviour was fooling everyone around him until I brought forward the comments made about me just a few short days earlier that were now being directed at the treatment team and I enquired as to who would be the next focus of his attacks. It become evident that John did not believe he had a problem and that everyone else was accountable for why his life was as miserable as it was… including everyone now trying to assist him. He was looking for someone who would respond negatively to his criticisms as an excuse to state that he made every attempt but he was turned away at every opportunity for care. To disprove this stance I was able to work with the treatment team to have him fast-tracked into the system in order to clearly display everyone’s willingness to assist him and that should this go sideways it would be due to his own decision-making.

John eventually completed his care; he even stayed longer than required in inpatient treatment as he discovered that his problems were much more significant then he would originally explore. A year to the date of his entry into treatment John called me and asked if he could come see me again which of course I obliged. He needed to see me face-face to thank me for “sticking” in with him through the insults, the complaints, and the bad-mouthing of my professionalism. I state this not as a pat on my own back but to show that when we work with the addict initial accountability is often elusive and we must see their story in the bigger picture if we are to help. Here is a man that was now over a year abstinent from mood-altering substances who when he first sought care did everything in his power to avoid that admittance and hoped to accomplish this by distancing the very people that could help him. I was not going to be just another justification in his long history of addiction!