You know you are in trouble as a Clinical Director when you get to work and all of your staff members, including those whose shifts ended earlier that morning, are gathered for your arrival. You are in more trouble when most of the current clients are standing behind them also waiting for you. When they have a spokesperson, you can rest assured that this is not going to be your best morning. That's the scene that greeted me on a spring day in 1974. The spokesperson blurted out the problem, "This man has made a mockery of everything this program stands for," and then catalogued the dastardly deeds the referenced client had committed in the four days since his admission. I had to admit the list was impressive. It seemed this client had found a way to break nearly every rule in the house short of those that would have gotten him instantly expelled. As the list of major and minor misdeeds was finally completed, the spokesperson pointedly concluded, "And we want to know what YOU are going to do about it."
Knowing when I am outnumbered, I stood tall and suggested it was time to have, in the vernacular of the day, a little "come to Jesus" meeting with this client. The client was quickly retrieved and a general meeting of the treatment community ensued in which we reviewed the client's nasty behaviors and made our expectations for the client exceedingly clear. In short, we drew a proverbial "line in the sand" and made it clear that the next time the client crossed that line he would be thrown out of the program. Assuring us that he understood, the meeting adjourned. The rest of the day passed quietly until I received a call at home that night about 10:45, reporting that the client refused to go to bed (there was the usual in bed, lights out rule that all were expected to follow). Now, suppose you were the Clinical Director. How would you have responded? I threw him out of treatment, and did so with a fair amount of gusto.
When I arrived the next morning, smiles were on everyone's faces and I received pats on my back for "sticking to my guns." I must confess to feeling pretty good about how I had handled the whole thing?at least until I got the phone call from the local judge who had mandated the just-expelled man to treatment with us. As I recall it today, the judge said something like the following:
Let me get this straight. I send you a man who has lived in every manner of deviant culture?a man who has committed every kind of unthinkable crime. And you kicked him out of treatment because he wouldn't go to bed on time?! I sent this man to you for treatment, not for charm school! (Phone slams).
I still feel sheepish about that call. But things got worse after it. This client had several prior treatments, and we had dutifully obtained releases of information from him to get copies of these earlier records. Days after his extrusion, these records slowly trickled in?long after we needed them. The discharge summaries indicated four prior residential treatments in which the client had been administratively discharged during the first seven days of treatment for failure to comply with program rules. Who do you think was in control of this man's treatment? It sure wasn't me or my clinical team.
I am convinced that the client I expelled that night walked down the steps of my facility with a bitter smile on his face, muttering, "Just like all the others!" His view of himself and the world was untouched. I believe he left my treatment program with less capacity for future recovery than when he arrived. The client, consciously or unconsciously, played me and everyone else in the treatment milieu. And I played my own scripted role perfectly, if unknowingly.
In your career, you will encounter many clients with chronic self-defeating styles of "doing treatment." Such styles constitute a major source of self-sabotage in early recovery efforts. It is as important to understand such styles, as it is to understand the nature of each client's substance use patterns. By recognizing and understanding such patterns, we can alter the script, refuse to play our programmed roles, and write alternative outcomes. We can avoid being played or therapeutically use the experience of being played as a turning point for the client.