Have you ever been asked on a job interview for a prospective new social work position: How would you react to a person who just walked in and appears to be under the influence of drugs or alcohol?
To help you be prepared for such a question, I consulted with two social workers who are currently teaching and/or working within the substance abuse field.
Based upon an exchange I had with an experienced social worker who is both a professor and a clinician in the field, the recommended response would be something like:
It would depend on the setting, but generally I would encourage the person to reschedule and come back on a day when he/she has not been drinking or taking drugs. Alternatively, I may encourage the person to go to a detox facility if this issue appears to be a chronic problem.
All of this would be done with a caring attitude and encouragement for further treatment. There would be no point in my seeing someone who is high, drunk or nodding off; it would be important to recognize that the person is impaired for the moment and may not even remember later what happened.
You may remember Lisa KaysMSW from her fascinating interview in A Day in the Life of a Prison Social Worker. Similar to the above clinician, Lisa feels that her response would vary depending on the specific setting, resources and agency policies, but she stresses the need to keep in mind both the clinical work and safety in these situations.
Below is Lisa Kays’ detailed response to this query:
First, the response will likely vary depending on if you’re in a residential setting or an outpatient one. For instance, when I worked inside the prison, I didn’t have to worry about someone driving home if I suspected they were high. I also didn’t have access to an immediate drug test, so I couldn’t verify if they were high or had used a substance.
In that case, it becomes a matter of clinical process, which usually included pointing out the client’s behavior or signs of use, i.e. “I notice that your eyes are glassy and you’re having trouble staying awake” or “I notice that you’re talking extremely rapidly, which you don’t normally do.” I would point out the signs of use, and invite the client to reflect on my observations.
Sometimes they would admit to use (in which case behavioral consequences of the program would take effect and a relapse prevention plan would be drawn up), but given the stakes, an admission wasn’t common. If the person is under the influence at the time, there probably won’t be a lot of deep reflection in that moment, so it might be more likely that my “evidence” would be presented in subsequent sessions when the client is more present to respond.
I think what’s most important is that I wouldn’t judge clients for using, or get angry, or take it personally or as an assault on our relationship or our work together. I would try to use relapse and use as a point of curiosity and to work with the client to use it as a means of self-reflection and learning, as we would anger in a session or chronic lateness. What led you to use? What triggered it? What is it costing you? How is it helping you? Are you interested in exploring other ways to cope?
With relapse or use, I generally assume that the client is already beating him/herself up enough and doesn’t need me to add to that voice. Instead, what is needed is guidance in better understanding this behavior and its impact on functioning, as well as alternatives.
We don’t yell or get mad when clients come in crying or being defensive or tell us stories of anger outbursts or marital strife. We work to understand this, to help the client understand this, and to provide skills to do it differently. I view use or relapse with much the same lens.
Now, in an outpatient setting things get trickier. Safety becomes much more concerning. I also have more tools, such as instant urinalysis or breathalyzers to assess and definitely know if a client is using.
As a result, if I or another staff member suspects use, we administer the appropriate test, and if it’s positive, take action, such as making sure the client has an alternative, safe ride home, updating a treatment plan, increasing their level of treatment, etc.
The one piece that I would add to the expert guidance provided above is to try to think of your response within the context of:
1. Defining the problem
2. Analyzing the problem
3. Generating possible solutions and
4. Selecting the best solution and course of action(s)
In this manner, you are given the opportunity to demonstrate to your prospective employer/supervisor not only what you think is the best way of handling this (or another scenario) but how you arrived at that decision.
Wow! This was really helpful! Thanks for doing this – and thanks, Lisa, for such a thoughtful answer!
It was my pleasure 🙂 Thanks for having asked a great question!
Thank you Dorlee for bringing this topic to light; it is a very difficult topic and one that deserves great consideration, especially for new social workers like myself.
As you know, I have been working in a mental health clinic for over a year. My initial reason for taking this position was because I wanted to work with children. I have been lucky in that 85% of my clients are children, and it gives me great joy to interact with and assist children in improving their lives. The other 15% are adolescents and adults. Most of the clients suffer with depression, anxiety, bipolar, and/or more severe mental illness.
I have received good supervision and I am thankful that I have been exposed to such a diverse population. However, I am not certified to deal with people that suffer with alcoholism or any type of substance abuse. I believe it takes a very special person, someone who is objective and empathetic to deal with substance abusers. I did not think that I had those qualities because of my own bias. I quickly realized that I could be very objective and although I was not certified to deal with substance abusers, I could use some of the tools I had learned to help this difficult population.
During the past year I was meeting with a client who expressed from the initial session that she had been using drugs since she was a young teenager. She came in every week (never missing a session) and talked about her life on drugs. She expressed the difficulties that she went through, the suffering within her family system, and how she became involved in drugs. She also mentioned that her sobriety had faltered many times but this time she would succeed at conquering her demons. I never asked her if she was still using drugs. I allowed her to explore and verbalize her feelings, but I often wondered if she was still using drugs.
I used the memories from my past to try and understand why some people are able to stop using drugs and/or alcohol and some people become addicted. I began by exploring the patient’s aspirations, hopes, dreams, and goals in life. I thought I was creating a new therapy for my patient (Yalom, 2003). I felt that somewhere in this person’s life was a child that had lost her way, and that her dreams and hopes had vanished. My job was to get that person to hope and dream again.
Although the person was an adult, I felt that some of the motivational exercises that I used with children certainly apply to people in general, (e.g., 3 wishes) and we began there. The patient needed to be heard, she needed someone to understand her, and she also needed to know that there was someone out there that would not judge her. I met with the client for almost six months and although this story sounds like the patient might have responded well, she did not.
As time passed, she became disorganized and confused. I was still not sure if it was the mental illness or substance abuse that was causing her to decompensate. One weekend, her husband called the clinic and expressed that she was hospitalized.
A part of me knew she had been using drugs, but I had been afraid to confront her or insist that she bring in an updated medical, which would require a urine analysis. I knew I had done all I could to help her, and as a new social worker I was proud of the work I had tried to accomplish. I also felt a sense of relief that she was in the hospital and would get the medical attention she needed, which would eventually help her to continue her road to recovery.
Although things did not go as I had hoped, I felt I had learned some important lessons. I felt a little bit smarter and wiser. I don’t mean to sound self-important by saying I felt smarter, but this was truly such a learning experience for me. I knew that my client had a substance abuse problem from our first meeting; I had read her chart, and the signs were all there.
She appeared hyper, her pupils were dilated, she could not sit still, she talked uncontrollably, and I did not address these issues. Don’t make the mistakes I made. I learned that there are times when you have to go with your instincts, that there were questions I should have asked and things I could have done better, to help my client.
The patient was referred by the hospital to a rehabilitation center, and although she is no longer my client, I understand she is doing well. It is now mandated that all workers at my clinic become certified and I am currently looking into getting my CASAC (Credentialed Alcoholism and Substance Abuse Counselor Program) certification.
As a new social worker, it is always important to ask questions, be considerate, empathetic, objective, and never ever ignore your inner self, but use it as a tool to be inquisitive and sometimes to be confrontational (when the time is right).
Thanks so much, Nancy, for sharing your experience in working with a client who had a dual diagnosis of substance abuse and mental illness.
You shared invaluable lessons – the key one for me being to listen to your instinct – if you feel something is true, question it (do not run away from it). That said, my gut feeling is that the trouble you had in confronting the client is not an unusual one, particularly for when one is just starting out in the field.
You were focused on establishing a therapeutic alliance with the client, the most important element in one’s work with clients. I think balancing the confronting part with feeling/expressing empathy is difficult and probably gets easier with experience (as you gain more confidence in your skills, ability, right/need to confront and knowing when you may confront without endangering alliance).
Motivational interviewing is one technique often employed in working with such clients. It just so happens that I will be taking a 3 day workshop in this methodology next week. If I happen to learn something in that program that could be of help, I will make sure to let you know.
Warmly,
Dorlee
Hi Nancy,
I just found out that there is a free “Working with Addictions and Recovery” Conference being held (online and in-person) this Saturday, March 23 that you may be interested in. Registration is available here: http://ow.ly/iOSTf
Hi! sorry it took me so long to post my comment.
I was asked such a question at my interview – except mine had to do with someone drinking on the bench in front of our door. We are a resource centre and offer crisis counselling. Some clients are regulars and others are ‘walk by’ – such as this man would have been. Our centre is situated in an area with a high concentration of alcohol, drug abuse, homelessness, poverty, crime, prostitution.
For the man on the bench – my answer was that I would go check on him, find out if he is OK. i would tell him he can’t drink there but if he puts away the bottle we can talk. There might be a reason he is drinking at that moment – or he could be a habitual drinker. It is important to offer him resources if he wants them (detox), hospital, a ride somewhere, bus tickets. We have a street outreach in the city that can help.
Anyways you see where I am going with that client.
With a regular client with an appointment – i would reflect the behaviour/ what I observe and depending on the level of intoxication, I would recommend making another appointment.
But – since we take ‘drop ins’ we do accept people as they are… as long as they are not violent, don’t disturb the safety of other clients and able to talk to us, we don’t refuse them.
Our philosophy is more one of harm reduction.
Hi Just a Diva,
Thanks so much for sharing the question variation you were asked and the response you gave. It was most helpful to learn that some agencies have a more lenient approach.
Based upon the description of your agency and the fact that you got the job, you seem to have given a response that was particularly fitting with the agency’s philosophy – to have that good a fit suggests you having done your homework prior to the interview – well done!
Thanks again 🙂