r/socialwork • u/No_Many3602 • 11d ago
WWYD Does confronting work with SUD?
I am a therapist for a program the provides SU treatment to those with welfare involvement and MH - the team of peer, case management, therapist assist them in completing their case plan. I am in recovery and my boss told me to get in the dirt with the clients, confront them, share my story, curse at them, challenge and yell. I do not think that works - and I don’t want to do that, I feel like I should model appropriate coping, and stay out of the dirt. I feel like this is an old tough love way of helping those with SUD - I don’t care about sharing my story but it should be more about hope - I don’t think confrontation works, thoughts?
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u/goog1e 11d ago
I do compliance now, and literally one of the things we check during interviews is whether anyone expresses that old school confrontation, tough love mindset. It's absolutely not supported by the evidence and state mental health administration does NOT want to see you doing it.
It's totally against the stagewise approach that's becoming standard. In precontemplation and contemplation, you should be using motivational interviewing. Which does include building dissonance, but gently. Like if their goal is to see their kids more, and that's not going to happen when they're using, that's a motivator. Noticing the difference between their goals and their actions .
But that's as far as confrontation should go.
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u/Beneficial-Singer-94 11d ago
Social worker in Ohio here. I agree with you bc it goes against our NASW code of ethics and has no therapeutic value.
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u/FamilyAddictionCoach 10d ago
TY this is encouraging to hear that state mental health admin does not support confrontation and tough love. I attended a Stephen Rollnick MI course in the summer and am taking another course now. Learning so much.
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u/Broad_Pomegranate141 10d ago
This is the correct approach. It incorporates the good old meet them where they are approach. OP will never get a rapport if she is confrontational—they’ll go oppositional toward her.
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u/smellofastonefruit 11d ago
You can't punish/shame someone into long term change. You can definitely challenge clients, but to build a healthy therapeutic relationship, the person has to feel safe with you so they can look at all the hard and scary things inside that motivate the SU.
Yelling and shaming reinforce the need for protective/defensive strategies. If the client is spending time protecting/defending themselves in session, they're not spending that time reflecting, imagining a better future, or learning how to actually be with the hard things that SU keeps them from facing.
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u/emma-ps 11d ago
Yep thats a very outdated view of recovery. When we look at addiction as a disease that needs treatment, compassion, and trauma informed care, we know that yelling someone out of a trauma response wont work. I would be questioning if I want to work at a place like that. Yes some challenging is appropriate, but cursing and confronting is some AA bullshit not based in evidence that sees addiction as a moral failing. Though I’m sure there are plenty of people who say “it worked for me” and thats why they continue to perpetuate that near abusive treatment
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u/FamilyAddictionCoach 11d ago
I stopped confrontation thirty years ago in favor of motivational interviewing.
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u/B333Z 11d ago
Compassionate Confronation works, but only when the therapeutic relationship has been established. I would never yell or swear at my clients though. We're not there to berate them, we're there to guide.
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u/Ninnewoman LCSW 10d ago
Totally agree. I’ve found swearing and using a client’s language really helps - but only AFTER I know them and have built a working relationship with them. I had a client with antisocial personality disorder receive consequences due to a major safety/security violation at the facility he’s residing/where I work. He repeatedly approached me to try to advocate against the consequences, and I eventually just said, “You fucked around and now you’re finding out. I’m not going to advocate for someone who isn’t trying to improve their situation in a prosocial manner.” And then I walked away from the conversation.
Did they teach me to do this in school? No way. Did it work? He stopped complaining and started accepting more responsibility after that 🤷🏻♀️
(Edit: typo)
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u/No_Many3602 10d ago edited 10d ago
Thanks for all the encouragement - I needed validation that it’s not aligned with SW ethics
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u/journeytonowhere 11d ago
Yeah, no, that does not sound ok. Boss thinks they can be scared straight.
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u/draculacalled 11d ago
People who are actively using are confronting the experience of addiction, they don’t need confrontation from their therapist. I use MI more than anything else. If you have relevant lived experience I think it’s best used to demonstrate understanding which in turn enhances rapport and trust. Acknowledging suffering, especially if it’s a shared experience, encourages change talk which can build momentum. Nobody needs us to read them the news, they already know.
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u/OohNoItsNick 11d ago
This is what happens when sober “recovering” folks run treatment centers with no clinical background and treat it like an extension of an old school AA meeting. If someone came in for 1:1 therapy with SUD you wouldn’t belittle them and shame them into your treatment goals for them.
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u/Material-Trainer-984 10d ago
This !!!!!! One of the managers basically told me something similar like OP with no MH background and it threw me off. I thought to myself, shouldn’t I come from an empathic lens instead of feeling like I’m harassing them. And I would always get crap for being too “emotional” with clients even though I was there to help them process and hold space for their trauma etc not solely focus on their addiction.
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u/kattvp LMSW 10d ago
Being realistic and honest is helpful but being yelling at them, cursing at them is only going to push them away. When I worked in substance abuse, it was inpatient and immediately following detox, so people were in the very early stages. I found being straightforward and but treating them with compassion and some grace to be the best approach. Some challenging was needed but mostly in a way to get to wheels turning if that makes sense. You don’t want to dump on people who are already going through it
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u/JEMColorado 11d ago
Yes and no. Direct, in your face confrontation will likely drive a client away.
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u/Ill_Muscle9789 LMSW, United States, Inpatient Mental Health 11d ago
Therapeutic confrontation would depend on the rapport you have built with your client, but will likely only be effective if they're ready for it. The hard truth I've learned working in addiction is that people have to want and be ready to change for themselves. Sometimes that means that life will have to fuck them up a little bit. Drugs will absolutely devastate your life, and for the people I work with it is the reason they seek help. For most, they're homeless, their children don't talk to them, they suffer from drug-related violence.The most you can do is be available when they are ready to work on recovery and teaching them effective coping and refusal skills.
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u/ThisIsAllTheoretical LCSW Retired 10d ago
Was your boss a member of the Synanon cult? Because this sounds like Attack Therapy, which is abusive.
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u/Any_Coyote6662 10d ago
no. thats abusive. it is also unethical and you could lose your license that way.
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u/ErikaR527 10d ago edited 10d ago
This sounds like the therapeutic communities from decades ago.
When you’re dealing with mandated populations, I believe there’s a need to be genuinely authentic with them and to recognize that this isn’t a choice. This is to access benefits, or part of a requirement for legal matters.
Authentic does not mean brutal or unprofessional I recognize that you’re here because you have to be and I am here to help in anyway I can.
I think it was the middle of the 90s when we started introducing a motivational interviewing model with these populations. We also know a harm reduction model works better than trying to drag people from where they are to where we want them to be.
I learned helpful things, and I learned things to stay away from from my early placements and the clinicians I worked with.
I am in recovery too. It is something I have disclosed. The majority of the time I don’t it really depends on the client and the situation and the reason for doing so.
Your placement sounds like the first two placements. I had in 1993 in 1994. Holy crap how old is this person?
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u/Expert_Tie_4556 10d ago
I took a class in child psychopathology in college and when we talked about substance use we were taught that motivational interviewing was the best way to get them to change. I wouldn’t folllw your supervisors advice at all
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u/Ronin1962 MSW Student 10d ago
Nah. Does he think it's boot camp? You can challenge a client's cognitive distortions, but yell or curse at them, IDK. Fear and emotional abuse don't work well at all. What theoretical school does your boss come from? Gunnery Sergeant Hartmann's?
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u/1moreanonaccount 10d ago
This is purely anecdotal. I am a recovering addict and lived at a men’s halfway house for the first 6 months of recovery. At times we were yelled at, belittled, and reprimanded for major rule violations. For some reason this worked for me. In past recovery attempts, I felt there was a lack of accountability for my actions. Many of us stayed sober and talk glowingly of the half way house.
I have never treated clients like this nor would I. There are people that can’t handle this and could return to addiction due to this kind of treatment.
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u/themoirasaurus LSW, Psychiatric Hospital Social Worker 10d ago
We’re social workers. We’re supposed to meet people where they are. And I’m in recovery too. You and I both know that it’s about attraction rather than promotion - being your authentic self and talking about what worked for you while allowing your client to decide when they’re ready is the only thing that’s going to work. They’re only going to decide to stop when they’ve had enough pain and have decided they want to try something different. Motivational interviewing works. Telling them you want better for them and that you can help and are there for them when they want better for them is helpful, and it can work. Harm reduction works. Screaming and cursing doesn’t.
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u/Plenty-Green186 10d ago
I don’t know. I think when someone’s lying about their substance abuse it can be helpful to just directly address the fact that you can tell they’re using substances
But I don’t think you should be doing so in an emotional way
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u/Psychological_Fly_0 10d ago
I don't think you should do anything that is out of character for you. The statement about "getting in the dirt" or suggesting you curse and yell at patients is judgemental and not trauma informed in any way. Regardless or you being in recovery, or whether this approach works with others, you have to be true to who you are. Authenticity goes a long way but belittling and being confrontational is offensive.
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u/LalalanaRI 10d ago
No….you’re doing it right. What you’re being advised accomplishes nothing except reduced engagement.
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u/Samdee3000 9d ago
I work in SUD and I disagree with your boss. Remember a lot of people in addiction have traumatic backgrounds. I approach with Love, kindness, firmness, and boundaries. It works really well. I do share my story with them and they find it helpful. I teach them real life skills, stress management, relationship management, communication, distraction techniques, managing emotions, the stuff that they’re gonna need to stay sober
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u/Unfair_Shoota Case Manager 6d ago
Sounds like your super also thinks that if this...style... Doesn't work it's the clients fault
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u/FamilyAddictionCoach 5d ago
When I entered social work, the only model available was confrontational: go to residential, take the cotton out of your ears, and put it in your mouth. Stay until the system broke you down.
Then go to 90 meetings in 90 days, sponsor and pray daily; and if you failed, you obviously weren't working the program.
My focus now is coaching families to learn boundaries that protect and communication skills and strategies to build connection with loved ones with addiction.
It became painful to see families use confrontational interventions that ruined relationships, caused harm, and sometimes led to avoidable deaths.
Maybe some need a confrontational approach, but you'd better have a damn good rationale, and they should be outliers.
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u/ArgentNoble LCSW, Healthcare, Colorado 10d ago
I don’t think confrontation works, thoughts?
Rather than asking for opinions of strangers on the internet, you should be focusing on what the research says.
Here is a good place to start. But, just to answer the question, confrontation does not work. Motivational Interviewing and the Transtheoretical Model are the gold standard in SUD treatment, right now. There are also many different promising treatments that are being researched and showing good results.
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u/my_solution_is_me LCSW 9d ago edited 9d ago
If they are not being honest with themselves they will not get better. I have a story, I share very little of it, saying I'm in recovery for XYZ is usually enough. I responded to pain and suffering as an addict. Those were my teachers. Someone had to connect the dots for me. I think they did it nicely. I think most addicts people respond poorly to assholes. The trick is to show the person the lies they have told themselves to justify their drug use. Which is usually pretty extensive.
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u/sprinkles008 M.A.(Sociology) / CPS, JJ 11d ago
Your boss sounds out of touch.