John Wallace, PhD, CASAC
Director, Alcoholism & Substance Abuse Services, St. Vincent's Westchester, Harrison, NY
Patient Competence: A Neglected Dimension
Educating alcoholics and other substance dependent people about their illnesses and motivating them to do something about their addictions are clearly valuable efforts. We should not, however, assume that these necessary activities are sufficient to insure recovery. Many people in recovery educate themselves about their conditions, become motivated to stay sober, but then still relapse. Why is this happening?
Avoidance of relapse is surely multidimensional. However, one important but often overlooked factor stands out. This is the large issue of patient competence. A person may be very smart about addiction and may want to stay clean and sober but if he or she does not know how to do this, then they won't be successful. What are the critical competencies that patients need in order to increase the likelihood of staying in recovery after initial abstinence has been achieved?
The first set of competencies is a collection of important personal skills that relate to well recognized triggers to relapse, e.g., anger and resentments, anxiety, depression, fear of failure, stress, etc. Skills such as self-hypnosis, relaxation competencies, anger and anxiety management skills, self-management of mood and other similar techniques are terribly important skills to teach to patients.
The second set is a collection of capabilities that involve work. For the unemployed person, all of the skills involved in finding and holding down a job are critical. For the employed person, a different set of considerations comes into play. Learning to manage job related stressors; dealing with difficult bosses or subordinates, handling the complex interpersonal transactions involved in most work situations and achieving a realistic and satisfactory set of expectations about work are examples of the types of competencies patients need to achieve in recovery from chemical dependency. For some people, the issue is not finding a job but understanding how to find or create work that is meaningful and fulfilling.
The final group of competencies involves love and other intimate relationships. It is certainly true that many people in recovery relapse because of the pain associated with love and other intimate relationships. They simply do not know how to manage the complexities of the situation. Many people in recovery seem to choose or create the same problematic relationships over and over again. They seem incapable of making good choices or developing satisfying and fulfilling relationships once their choices have been made. In such matters, people need wise counsel and expert instruction.
Must we stop educating and motivating patients? Of course not. It isn't a matter of either/or. We should, however, recognize the full implications of a patient competence and capability model of recovery in chemical dependence and begin to fill in the mising factors. Patients need to know how to stay clean and sober, and that means, patients must learn a myriad of associated skills, competencies and capabilities if relapse is to be avoided and a fulfilling recovery achieved.
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