“Hey doc, are you in recovery too?”
Patients sometimes express curiosity about their therapists by asking them personal questions. When treating patients who suffer from alcohol and other substance use disorders, it is not uncommon for therapists to be on the receiving end of questions such as, “Are you in recovery too?” or “Have you ever used [insert name of substance]?” or “Haven’t you ever binge-drank?” When this happens, therapists need to be prepared to answer in a way that preserves proper boundaries without shaming or being dismissive of the patient. Therapists can also conceptualize the reasons behind the patient’s asking the question, as this may help them to craft answers that are most apropos for a given patient. Having said that, how is a therapist to reply, and what are some common conceptualizations of the patient’s question?
First, remember that patients who are familiar with 12-step programs such as AA and NA may be accustomed to working with sponsors, who themselves are in recovery.
These sponsors also attend the AA and/or NA meetings, they acknowledge their vulnerability to addictive behavior(s), and they serve as mentors to people who are newly trying to work on their alcohol and other substance use issues. Personal information is readily shared between sponsors and their sponsees, and the boundaries generally are not as formal as in professional therapeutic relationships. With 12-step meetings as their model, patients may believe that it is reasonable and un-intrusive to ask about their therapist’s recovery status. In such cases, therapists can kindly explain the distinction between sponsors and therapists, and how the boundaries differ.
Therapists may also hypothesize that their patient’s questions serve a function, and/or reflect a particular belief that the patient maintains. For example, perhaps the patient believes that being in treatment puts them in a vulnerable, “weak,” or otherwise disadvantageous position, and that determining that the therapist is also “working a program of recovery” will level the playing field. Cognitive-behavioral therapy already places a premium on creating a collaborative therapeutic relationship, and often this is enough to allay the patient’s concerns about being in a one-down position.
The patient’s question may indicate feelings of indignation, as if to imply, “If you’ve been a problem drinker/user, then you’re no better than I am, so why should I listen to you?” Again, cognitive-behavioral therapists are trained to be humble and respectful, and therefore they are rarely unduly forceful in providing psycho-education, interventions, and feedback. Patients therefore typically come to see that they are not being coerced to change by an authoritarian, but rather they are being offered help by a benevolent, well-trained professional.
On the other hand, some patients may hold the belief that their therapist needs to have suffered from addiction problems in order to truly understand, and (by extension) to offer relevant help. Such patients may be inclined to reject the feedback of therapists who have “never been there,” or “don’t get it.” Does this mean that the therapist needs to admit a personal history of alcohol and other substance misuse in order to preserve the therapeutic relationship, or (conversely) to argue that their personal history doesn’t matter? What is the therapist to do?
There is no single rule in this case, other than being mindful that the treatment needs to focus squarely on the patient’s life and needs.
Different therapists have a range of comfort zones, and some are more willing to self-disclose than others. The keys are to be humble, to offer rationales for their approach to treatment, and to validate the patient’s concerns. That said, here is an answer that I typically provide my patients who ask me questions about my own history with alcohol and other drugs:
“It’s reasonable for you to ask that question. Of course you want to know how well I can understand what you’ve been going through. Of course you want to see if I practice what I preach. I definitely want to understand you well, so I can offer you the best possible help that is tailor-made to your goals. I certainly intend to be a good role model for using cognitive-behavioral methods on myself so that I can be hopeful, level-headed, and a good problem-solver even when the going gets tough. But here’s what I’m going to ask of you. I am going to ask you to judge this treatment on what you see for yourself, rather than on assumptions based on what you think about me personally. I am hoping that you will evaluate this treatment on its own merits, on what it provides you in terms of support and skills, rather than on any preconceived notions you may have about me. That’s why I am going to humbly decline to answer your question about my own history regarding recovery. It’s not because I’m dismissing your concerns, or because I think I should be exempt from dealing with the subject myself. It’s because I want you to evaluate this treatment as objectively as you can, based on how well we work together. What are your thoughts on that?”
I should add that I believe that there are times when it is appropriate for cognitive-behavioral therapists to give a more direct, personal answer to the patient’s probing questions, provided that there is a good rationale, while taking care not to let the therapeutic dialogue morph into a more regular sharing of personal information. The term I sometimes use is “surgical strike self-disclosure,” in which the therapist answers a personal question succinctly, on point, on a matter of direct relevance to the patient, and then the therapeutic agenda promptly returns to focusing on the patient. Whether or not the therapist chooses to provide the patient with this type of self-disclosure is a matter of personal style, taking into account the case conceptualization along with a strong therapeutic rationale.
CBT for Substance Use Disorders
March 25-26, 2019