In the offering of addiction treatment, this article presents one clinician’s method to reflect feelings and actions with respect to transference and counter-transference.
The process of outlining phases of care in outpatient treatment offers a framework to remind myself where I am and where the patient may be. This is important because addiction care is one of the most wild and chaotic clinical rides around. By dividing the care into phases, it offers a way to look at the issues and to decide if they are mine to own or indeed the patient’s issue. Of course, good regular supervision is always wise in order to stay balanced when providing addiction treatment – this is too difficult a field to work in without good support. Of important note as it pertains to this subject is the phases I use here do not match Porchaska’s Stages of Change  or Mee Lee’s Dimension model, yet all the models do interact and work well together with these phases.
You may want to add examples of feelings and reactions each of these phases, and I would invite you to do so as you notice your own issues surfacing.
1) “I’m Desperate to Stop the Pain”: This first phase is when the patient is feeling ready for change. They may have called several therapists and left urgent message(s) with each to call back and schedule the first possible opening for an appointment. Often the patient does not tell the therapist that they have called other providers. So there is a professional race to return calls and set up a time to meet. This seems a waste of professional energy.
My policy is to return all calls within 24 (business day) hours of the call. If I have an emergency opening, I try to fit the client in, though this often comes at the same time that I could have had with my family instead. (One of the busiest seasons in my private practice is during Thanksgiving, Christmas, and New Year’s, which is when I receive most of these calls.) Certainly this is no coincidence that I get extremely tired when the things I enjoy doing with my own family and my work conflict.
The bottom line for me is that I understand that the nature of addiction is to want to stop the hurt, and so this phase doesn’t bother me too much, other than feeling tired.
2) “I’m All Fixed”: In this phase I often don’t connect again with the patient when I return their call because I learn that they no longer need help, or because another therapist already booked an appointment with the patient just moments earlier. It is sort of a false start to providing care because I have gone through the effort to free up my time, but the patient does not want to use it.
I am hurt each time this occurs because of the unpaid effort for me to arrange the time to contact them, fill out the paperwork, set aside a time in my busy schedule, check insurance coverage, and then take the time on the phone with them. Front desk and clinical screening staff in larger practices help reduce this problem, but in a solo practice, there is no easy answer to this time and effort spent.
In this “I’m all fixed” phase, something more subtle happens now that we are dealing more with managed care insurance than people paying out of pocket. What was once considered as needed help from an expert has turned into insurance panels taking the role of expert specialist in the field, homogenizing it into more of a contact provider list for the client. From the client’s perspective, all insurance providers appear to be the same, since the insurance lists them all together. The “expert” evolved into the “provider” over the years.
The patient with insurance often is not as invested in change as is the private paying patient because the latter has already done the work to prepare, literally, to invest in themselves. Here, I get bothered, not as much by the patient’s actions as by the insurance movement and the lost revenue I suffer for my efforts. More work for less money at times.
3) “This is Way too Hard”: Here the patient suddenly stops the treatment process. The first clues of this phase may be found by the therapist in the Clinical Intake Evaluation, when asking the patient about their previous care. Sometimes clients give a long list of therapists they previously saw; each time I ask why they changed therapists. This allows me to hear what the patient may not have previously liked or gained from therapy, and I can use that to help the patient make more specifically tailored clinical goals this time.
The patient quickly finds that therapy is difficult, requires honesty, and involves change. Some patients can verbalize this process and some will speak with their feet by dropping out of care very quickly. They may continue (hopefully) later in treatment when the pain is greater. More than likely, though, they really haven’t moved out of the I’m all fixed phase and haven’t yet accepted the work they need to do. It is the same when the client enters into treatment for the first time or returns after treatment with a different therapist.
It is not uncommon to hear that the therapist is now the problem for the client because he or she has suggested to them what needs to be done in treatment (e.g. attend 12-step meetings daily or stop using, or to attend a higher level of care because they can’t stop on their own). Some therapists do a disservice to the patient in this phase by not establishing firm and clear clinical sobriety-comes-first boundaries, and so the therapist spends time discussing issues that don’t have to do with the addiction. Often these therapists are well-meaning, but not familiar with working in the field of addiction. This disease kills and the use of substances and behaviors need to be stopped first. We can’t be detoured when the addict blames other people, places, or things.
Certainly, I struggle with this stage of care because it cycles fast and often. Perhaps this is why some therapists prefer to treat only the worried well. In addiction treatment, it seems I have the highest no-show rate from patients and the highest number of unpaid bills during this phase. I still have to put in a lot of clinical effort to diagnose and meet the new patient where he is. I still save time for them in my schedule need to complete all the necessary paperwork, but there remains a high drop-out rate in this phase.
To help balance these kinds of feelings in this phase, we need to remember our training. The hope in this part of the clinical dance, is a) to more deeply involve the client in ending the cycle of addicted chaos through motivational techniques and to start the process of wellness; b) for them to learn that, indeed, we really do care and understand what we are discussing based on our own experiences and training; and c) to build trust together in order to move ahead and to face the pain of change and learn a different way that works. If a client can accept that trust, then the next phase begins.
4) “I’m Engaged and Willing to Work”: This represents the concept that the pain of recovery is less painful than the pain of continuing one’s addiction. Here, the sessions are booked in advance and the patient accepts the work that needs to be done. Of course, relapses can cause recycling through the previous phases of care, but once someone is truly in this phase, the bulk of clinical work is actually done.
Getting the amount of authorizations for the insurance coverage of care may be a clinical issue for the therapist sometimes, because by this phase, the acute stage has settled into remission and the healing of the symptoms seems completed. This is the maintenance stage and may take months or years and longer.
Chronic illnesses and co-occurring diagnoses take even a longer time to treat. Bipolar disorder, for example, requires a long period of care to stabilize, as does trauma work. Some diagnoses may be difficult to get authorizations for long enough care, but I find good clinical documentation usually makes the process work for the patient.
I enjoy this aspect of the addiction treatment because it involves dealing with wellness: physically, intellectually, emotionally, and spiritually.
5) “I Think I am Ready to Stop”: Sometimes the patient knows this and brings it up, but usually it is the therapist who brings up the topic first as the session frequency is reduced down from weekly to every other week, toward ending treatment. We start to discuss how this stage is normal, and I outline how ending care can be accomplished.
When treatment has achieved the goals it set out to accomplish and has successfully dealt with the care needed – with no new major issues appearing – then it is time to move to terminate treatment.
In this phase, discussion of the ending process with the patient is begun by reviewing her history going back to the initial reason for seeking care in the beginning, and progressing over time and the therapeutic efforts in the changes she made. I do this to both offer closure for them and for me. I feel sad to end with some patients with whom I have worked for years because of how deeply I have been able to witness their life’s journey in their healing. When a patient ends abruptly, I feel like I don’t know how they are doing. It is like reading many different books without ever getting to the last chapter. It feels unfinished and there is some grief there.
Our professional work is always about helping the patient. I have to remember these people are not friends: they are and always will be patients and maybe they don’t know how to end a healthy relationship because they never learned.
In conclusion, there is never enough time or space in an article such as this to really work through all these issues. They are on going for each of us within this very difficult topic of transference and our counter-transference in addiction treatment. I welcome discussion and would encourage conversation on how you cope and what methods you find helpful to deal with these topics.
Thomas A. Peltz, MEd, LMHC, LADC-1, CAS
Mr. Peltz has worked in the mental health field since 1973. His private therapy practice office is located in Beverly Farms, MA. Please see: www.tompeltz.com for more information.
 Peltz http://www.addictionpro.com/article/facing-spirituality-head