Of Mice and Men–or Part of the Difficulty of Working With SUDs

There are a lot of exceptional programs for people with SUDs—substance use disorders—with great people running them.  There are tons of great parents, really caring school administrators and counselors, solid people handling probation and diversion cases, and on and on—please take in this post knowing that while I have thoughts and critiques for the process, I don’t hold myself above anyone struggling with the complex challenge of supporting individuals with SUDs.  -JH

In my experiences, working with individuals using or misusing substances can take on the feel of a “cat and mouse” game.  The cat is whatever authority is in the picture—a parent, teacher or school administrator, law enforcement, SUD counselor, et al.  The mouse is the person using.  I have worked with adults mandated by court to stay away from all illegal substances.  I’ve also worked with teens whose parents had drawn a zero tolerance line in the home that the teens were struggling with.  These teens were often suspended or expelled from school (or close to it), had legal citations and were sent to a juvenile diversion program, required to enter a rehab program, etc.

In many of those cases, part of the problem was the cat and mouse feel that the case had taken on.

Consider the cat waiting at a little hole in the baseboard of the house, pawing at the opening and trying to catch the mouse hiding inside.  If you’re old enough you can picture Tom and Jerry, the cartoon I watched when I was little.  Jerry the mouse constantly eluded Tom the cat by running, hiding, or fighting back (usually in some ultra-violent way—ah the old cartoons!), and Tom relentlessly pursued the mouse, often getting hurt in the process.

Teens and adults caught under the paw of authority are usually straining to escape.  The probationer or parolee just wants to “get off paper”—out of the system and the watchful eye of the law enforcement that’s ensnared them.  The teen attending expulsion school just wants to get back to their regular school and friends.  The young adult at home wants their parents to stop nagging them and let them make their own decisions about using marijuana, or pills, or whatever other substance and behavior of their choice.  The teen in a program is often just dying to get out of the program.  It’s true that some take whatever opportunity they’ve been given forced into, to make some needed changes and improvements, but this dynamic is real and problematic.

One of the only ways that the authority in the picture can know for sure that the individual is complying with home/school/program expectations is to use urinary analysis—UAs, or your basic drug screen.  A UA kit can be purchased over the counter from most pharmacies for home use, and many SUD programs require regular and randomized UAs to monitor compliance from the individual.

There are some common pros and cons to the UA/compliance model.  The pros include knowing that someone has refrained from using substances X, Y, and Z for X amount of time, regaining a sense of control over an out-of-control situation, trusting someone when they claim to be “clean” or identifying when they have been deceitful about their use.  The cons include an individual feeling more trapped and monitored, without control over their decisions, resentful and angry, or another popular strategy:  finding new ways to avoid detection of illicit substances in their urine.  They flush their system by drinking gallons of water, buy cleansing systems from their local head shop or an online source, use someone else’s clean urine, use designer drugs that are still undetectable to common UAs, and a whole litany of other methods I won’t go into great detail on here.

The bottom line is that often, the cat and mouse dynamic only intensifies–at least at the start of treatment.  The drug testing locations monitor the actual urination to make sure the individual is the one providing the urine, intensifying the resentment over being more closely monitored.  The authority in the picture considers any sample that is diluted by those gallons of water to be a positive result, even if that individual hadn’t actually used.  Timeframe goals (e.g., provide 2 months of clean UA results to regain the trust of the parent/school/judge/diversion counselor) are reset to zero, and eventually the individual can feel like they are at the bottom of a deep pit with walls too slippery to climb out of.

A sense of futility sets in.  The authority tires of constantly watching the mouse hole.  The individual tires of constantly losing and trying to regain the trust of the authority, who is really just a great big paw holding them down anyway.  People I’ve worked with have often come down with a severe case of the “forget-its.”  Except the phrase isn’t “forget it,” but a similar F-word phrase I’ll not write here but I’m guessing you know, regardless.  FORGET THIS! they exclaim.  FORGET YOU, and the SCHOOL, and my BOSSES, and the PROGRAM, and the JUDGE, and my PROBATION OFFICER, or the DIVERSION COUNSELOR—FORGET YOU ALL!!

Deep breaths.  Although this is a common dynamic in working with SUDs, it is one we can break out of.  A kid and their family can find common hopes and goals—the success of the system in the home, graduation from high school, holding a job and saving money to move out, etc.  An individual can decide that their job or their family or their relationships are too important to endanger any longer.  The authority in the picture can learn to “roll with resistance” better while still drawing and maintaining reasonable boundaries.  It’s possible to use UAs to demonstrate and celebrate success and gain trust, instead of catching and punishing someone with harsher penalties for their noncompliance, or booting them out of whatever program they are in.  We can view setbacks as the natural and expected process of recovery, and learn from them while still keeping on our upward trajectory—two steps forward and one step back is still one step forward!

Still going up, right?

Finally, we can have grace with each other in difficult situations, recognize the humanity in the cat and in the mouse, and never treat people—moms and sons, fathers and daughters, counselors and clients—like cats and mice again.  We can toss a new and smarter and stronger lifeline to the person at the bottom of the slippery-walled pit, as everyone steadily pulls up and out.  Hope is a hard thing to have in some of the situations I’ve described in this post.  But it isn’t cliché to say that hope is the thing we need to protect the most.  And sometimes in my practice, I can only start by saying, “I see you.  I get it that you’re low on hope.  Your motivation is at or near zero.  I have some for you, and I’ll share it until you find yours again.”