Discussion

Background

Free floating denial: In your text, it is noted that clients with co-occurring disorders often demonstrate different forms of denial, depending in part on the skills and training of the professional interviewing them. Contrast the following two hypothetical interviews. The client is a man who is assumed to be 25-year old and is recovering from the aftereffects of a head injury he suffered while intoxicated:

Counselor: So, we are meeting here to discuss your substance use, to try and determine whether you have a substance problem.

Client: Can you speak up a bit? The accident left me with a hearing problem.

Counselor (speaking more loudly): In the year before your accident, how often would you say you would drink alcohol in the typical week?

Client: I can’t remember much of the year before the accident. I was told by the doctors that I probably won’t be able to regain any of those memories back.

Counselor: All right, how far back does your memory allow you to recall things clearly?

Client: Two or three years back.

Counselor: Then describe what your alcohol use pattern was like 2–3 years ago.

Client: Oh, it was not a problem back then. I hardly ever used alcohol. But I can’t remember clearly, because of my head injury. Sorry.

Now contrast this with the following hypothetical interview between a physician and the same client the next day:

Physician: Well, you seem to be recovering quite well. But your alcohol and drug misuse bothers me.

Client: Oh. The counselor told me that I don’t have a problem. We discussed this yesterday and he said that I did not even seem to misuse alcohol. I never use drugs, so that is not a problem. But my shoulder still hurts me a lot.

Physician: Does it hurt when you move your shoulder in a specific way, or does it hurt all the time?

Client: All the time. Can you give me something for the pain?

In this hypothetical set of conversations, you can see how the client shifted the focus away from his substance use to his medical condition when meeting with the counselor, and then away from his substance use to a physical problem when meeting with the physician (with a ploy to obtain painkillers tossed in for good measure). Thus, clear and continuous communications between the professionals who are involved in the patient’s treatment is always necessary. For example:

Counselor: So, we are meeting here to discuss your substance use, to try and determine whether you have a substance problem.

Client: Can you speak up a bit? The accident left me with a hearing problem.

Counselor (speaking more loudly): Really? Dr. Smith did not mention that in his notes. I will have to mention it to Dr. Smith when we meet later this afternoon and Dr. Smith will want to discuss that problem with you. But let us move on. In the year before your accident, in a typical week how often would you consume alcohol?

Client: I can’t remember much of the year before the accident. I was told by the doctors that I probably won’t be able to regain any of those memories back.

Counselor: Hmmm. The neuropsychological test results did not suggest either short-term or long-term memory problems. It is strange that you cannot remember that information now.

Client: Can I see the report?

Counselor: You can discuss the report and the conclusions with the neuropsychologist after we are finished. Right now, we are discussing your alcohol use in the year prior to your accident. . .

Discussion Questions

  • What changes do you notice between the third dialogue and the first pair of dialogues?
    What practices caused those changes?

Additional information