Supervision for Addiction work - What makes it so different?

Supervision for addiction work is different because addiction work is different! Over my three decades of addiction work and supervision in clinical and teaching settings, I have observed time and again that treating addictions differs in a number of key ways from many other areas of therapeutic work.

Take confidentiality – innate to the therapy contract - for example. We cannot, in the best interests of the addicted client, offer the same broad confidentiality agreement we would normally guarantee to our clients. The clinical picture of addiction includes behaviours such as secrecy, lying and manipulation. The progression of the addiction is accelerated by these behaviours. Those working in the field are well aware that ‘Addiction breeds in secrecy’. It is thus counter-productive to agree to withhold information from the client’s family and significant others. They need to be allied and informed, thus avoiding “gaps” in the treatment process.

Let me stress at the outset, in light of the negative behaviours listed above, that addicts are not “bad” people. Addicts are mostly good people struggling to manage a chronic illness. Unlike other chronic illnesses such as diabetes, active addiction leads to behaviours which evoke very negative responses from others. Addiction is thus linked to stigma and judgement. However, when addicts have established a working recovery, they often live far more self-reflective and honest lives than the average non-addict.

The differences in the nature of addiction work speak to the requirements of supervisees in this specialized field. Helping supervisees to recognise and manage the challenges particular to addictions will empower them to work more effectively (and happily!). The supervision should be multi-faceted, including reflection on emotive aspects as well as practical guidance. Let us focus on the two core areas of therapeutic alliance and case management.

The Therapeutic Alliance

I believe the essential primary role of supervision is assisting supervisees to become conscious of what is transpiring in the relationship between themselves and their client. Awareness of the client’s transference and of their own counter-transference is an essential and valuable tool in the therapy process. But if unrecognized these forces operate unconsciously, threatening the therapeutic alliance, and doubtless the supervisee’s motivation to stay in the field of addictions.

Some aspects of addiction work which impact particularly on the therapeutic alliance include personal experience of addictions; trust; and the client’s ambivalence.

Personal experience of someone else’s addiction is extremely common. On average 17 people around every addict will be negatively affected by his* behaviour. This means that the supervisee is very likely to have been affected in some way by an addict in her* personal life – be it a family member, work colleague or friend. This can lead to negative counter-transference when encountering an addict professionally. For example, the supervisee’s uncle caused endless problems in the home during her childhood due to his drug abuse. She meets with a client who displays similar behaviours towards his family. She struggles to feel empathic. She also feels intimidated, re-experiencing some of the fear she felt as a child.

Trust is something we can normally expect to feel when working with our clients – trust that they will be truthful about their history, symptoms, concerns and challenges. Why would they not want us to have all the relevant information about their lives, so that we can best be of assistance to them? With addiction work this is an assumption we cannot make. We are more likely to find that denial and dishonesty will play out to some degree. For the supervisee it is a challenge to learn to work without the comfortable baseline of trust in her client’s honesty. For example, a client reports during a session that he has been abstinent since starting therapy, even giving examples of how he applied the relapse prevention strategies suggested. A surprise drug test conducted after the session proves positive for drugs. The supervisee feels dismayed. She has a sense that the client has “made a fool” of her. She feels she should have known he was not being truthful.

Ambivalence is invariably present in addiction work. Addicts, no matter how motivated they appear, and whether self referred or forced into treatment, come with mixed feelings about changing their behaviour. Why is this? On the one hand there have been negative consequences – even chaos or near-death – which have brought them into treatment. On the other hand, their drug has been their best friend, lover, coping mechanism and priority for so long. It can be terrifying for the addict to consider life without drugs. This ambivalence can be confusing and frustrating for the supervisee, like treating 2 diverse people in the same body! For example, an alcoholic client spends a session gaining insight into his lack of control over drinking, and the unpredictability and turmoil drinking causes in his life. He states emphatically that he knows he cannot risk picking up a drink again. The supervisee feels excited and effective about this progress. It is then disappointing and disheartening when the client’s wife calls the next day to say that he relapsed the previous night and caused a car accident.

Case Management

While reflection on the therapeutic alliance speaks to the “how” of addiction work, supervisees also require assistance with the “what” of treatment - the management of the case. Taking into account the nature of addiction, supervisees should be encouraged to reconsider their ‘tried and tested’ therapeutic approaches. What normally works well for clients may indeed be futile or even regressive for addicted clients.

Some areas of particular concern in managing addiction cases include the risks associated with drugging; the drugs themselves; and the family.

The risks of severe harm or death are ever-present within the nature of an addiction. An addict may become depressed and suicidal due to his situation. But even a non-suicidal addict may quite possibly die of an overdose; be raped visiting a drug merchant; or get into a fight or accident when intoxicated. The supervisee can feel powerless and afraid as she observes these risks looming for the client. She may experience vicarious trauma regarding events the client reports.

The drugs are themselves a presence in the therapy process. Some drugs are legalized, such as alcohol and more recently Marijuana, thus enhancing the client’s ambivalence and denial. Certain addictive medications such as Benzodiazepines and Codeine are readily prescribed by doctors - this medical sanction providing the client with justification to use them. The supervisee may find herself trying to “convince” the client that legal substances can also be problematic for him. She can easily feel compromised and inadequate by gaps in her knowledge. For example, she lacks information about certain illegal substances. She is unfamiliar with some slang names for substances. She is unaware of a new drugging trend emerging on the street. Whether legal or illegal, all drugs can present the supervisee with self-doubt and bewilderment.

The family - Addiction is a family illness. All those close to the addict are affected. All need help in finding recovery not only for the addict but also for themselves. The family of any therapy client can of course present challenges for the therapist. The family members and significant others affected by an addiction are, however, especially likely to display strong sentiments about the situation. By the time they reach professional help, they are usually experiencing overwhelming emotions such as frustration, helplessness and anger. Families of addicts tend to adopt counter-productive roles in dealing with the addict, such as rescuer or persecutor. These roles are well intentioned but invariably obstructive to the treatment process. The supervisee may face impossible expectations and unrealistic demands from families. For example, a client’s parents insist that their son, who is stealing to support his habit, be placed immediately in a long-term free rehab centre. They are unwilling to hear about waiting periods for limited beds in community resources. They tell the therapist she will be to blame if the addict is arrested. The rage and desperation they are feeling about the addict in their home has so easily been directed at the supervisee. She finds this alarming and undermining.

In conclusion, addiction work can feel terrifying. Enlightened supervision is indispensable and can allow the supervisee to enjoy addiction work rather than wanting to avoid it at all costs! The core areas of therapeutic alliance and case management are intimately linked. Tracking and processing the supervisee’s feelings and struggles impacts positively on both. Fundamental to this area of supervision is embracing and accommodating the divergences inherent in addiction work.

Cathy Karassellos | Clinical Psychologist

* For ease of style, clients are referred to by male personal pronouns & supervisees by female personal pronouns.
Image by MUHAMAD ZUL AZIMI BIN ABDUL RAZAK from Pixabay