What to do when your client arrives for therapy inebriated or otherwise under the influence

South Africa · CPD courses & CPD points · Health Professionals

It’s probably happened to all of us, more often than we think. A client arrives for therapy in an altered state. Either online or face to face. If they are a new client, you may not instantly be aware of this. You think that slow speech pattern might just be a personality quirk, particularly if they are onscreen. You can't see the size of their pupils. Sometimes they declare, “I smoked a joint before our session” and you wonder whether this is meant as a sign of trust. Sometimes they smell of alcohol, possibly, you tell yourself, just because of a boozy lunch.

The core thing about addiction is denial, and it’s catching. They’ll tell you it’s just a river in Egypt, and the next moment you’re drifting down it. Unfortunately, substance use is heavily socially sanctioned, particularly the use of alcohol. Heck, we might have had a glass of wine ourselves last night and now feel we are sitting in judgement of the client before us.

Doing therapy with someone in a mind-altered state is, in my view, inaccurate and inappropriate unless they have ingested plant medicines and met with you specifically for the kind of therapy that utilises such. The difference is in the contract, the intention, and the methodology.

Perhaps you are witnessing a cry for help and your client is unconsciously demonstrating their out-of-controlness by arriving inebriated or stoned to a therapy session. This is the definition of unmanageability. And might be a good place to start the conversation. Not, however, when they are under the influence. As when a child is angry and having a tantrum, and we know this is not the best time to communicate with them, just so speaking to a drunk or high person is not a good time to impart advice. Set a gentle boundary instead, terminate the session, and insist on a follow-up appointment. Indicate that this is rich material, that everything can be talked about and understood. Everything can be held gently.

In Alcoholics Anonymous, newcomers who cannot quite stop drinking yet have been known to attend meetings inebriated. This is accepted as part of the beginning process, that switch over from will (White knuckling/I can stop this with self-control) to surrender (This is totally beyond me; I need help from something greater than myself). Your therapy room or office is not, however, the AA.

Addicts who are actively using are under the control of “Slick”, to use a recovery term: it means their addiction is speaking for them. Slick speaks using denial, repression, lying, hiding, justifying, blaming and compensation. It does everything to steer away from honesty, accountability, and self-assessment. This is to keep the addictive side of you alive. It likes to nudge you towards the F*** It Button (“Oh, things are so bad anyway, I might as well… go to my session drunk.”)

So, once you have done the gentle holding and understanding thing, the non-judgement, and once you do have a sober client sitting in front of you, it is time to be direct. I find it helps to talk about addiction as the human condition – we all have coping mechanisms or “devoted habits” which is the what the term addiction means. The root word addict comes from the Latin word addictus (past tense addicere), which means “to devote, sacrifice, sell out, betray or abandon.” We all abandon ourselves at times in a misdirected attempt to cope. It is part of our conditioning and yes, it has been socially sanctioned over the ages (“Buck up” “Distract yourself” “Stay busy”).

I encourage you as the therapist to read the 12 Steps which are available online, because in an early recovery session you will be helping the client with Step 1: admitting they are powerless over the substance or process addiction that has them in its grip. Admitting. Something has me beat. I need help. This is the opposite of denial.

The 12 Step Programme is one of the most well-known and successful models in the treatment of addiction. In almost every city and town throughout the world, you can find 12 Step meetings – and there is a 12 Step group that focuses on almost any addiction, from narcotics to codependency, sex and love addiction, gambling, shopping, over-eating and cutting. All are forms of self-harm.

The programme, the steps and the meetings provide peer support and the correct treatment for your client. Admitting “I am an addict” is the first step to being restored to sanity.

Such an admission can be accompanied by huge amounts of shame, and Slick will attempt to use this painfulness to divert your client back to using. You can point out that shame, guilt, self-criticism, self-hatred, blame and judgement are all part of the old story, the original problem.

Entering recovery means we are prepared to investigate another story about ourselves, one of possibility, goodness, forgiveness, growth, humility and learning, which ultimately leads to joy.

Johan Hari said that the opposite of addiction is not sobriety, it is connection. Connection with ourselves, each other, and a Higher Power of our own definition. Connect with your client on a heart level but do not give Slick a chance. Make an appropriate referral, to a rehab if necessary.

Suggested Reading

(PDF) Addiction as Somatic Dissociation | Christine Caldwell - Academia.edu

Carnes, P. (1993). A gentle path through the Twelve Steps: The classic guide for all people in the process of recovery. Minnesota: Hazelden.

Carnes, P. (2012). A gentle path through the Twelve Principles: Living the values behind the steps. Minnesota: Hazelden.

Grace, A. (2018). This naked mind: Control alcohol, find freedom, discover happiness & change your life. New York: Avery.

Hari, J. (2015). Chasing the scream: search for the truth about addiction. London: Bloomsbury.

Hay, L.L. (1994). You can heal your life. Carlsbad: Hay House, Inc.

Helgoe, R.S. (2002). Hierarchy of recovery: From abstinence to self-actualization. Minnesota: Hazelden.

Maté, G. (2008). In the realm of hungry ghosts: Close encounters with addiction. Toronto: Knopf Canada.

Whitfield, C. (1993). Boundaries and relationships: Knowing, protecting and enjoying the self. Florida: Health Communications.