Initial challenges for clients and counsellors
Clients presenting for other substance use treatments are typically on a continuum from moderate to severe dependence, irrespective of the drug. In contrast, clients seeking MMT are virtually all severely dependent. Many have a long history of chronic injection drug use.
Upon entry to methadone treatment many clients feel desperate about their circumstances. Their lives are often chaotic and disorganized as a consequence of their substance use. They commonly present with a wide range of problems including some or all of the following: housing problems, dysfunctional social relations, occupational difficulties, legal and psychoeducational problems and/or health and family concerns (Ball & Ross, 1991). Typically, they have in the past tried treatment to overcome their substance use problems without success. Therefore, they may feel skeptical about their chances of benefiting from further treatment.
Clinicians working with these people must be knowledgeable about the various issues that affect their clients' well-being. These issues also include the effects of various psychoactive substances, safe health practices, and symptoms associated with mental health problems common among people dependent on opioids.
Early dropout from methadone treatment is high. Approximately 50 per cent of people who use heroin can be expected to drop out of treatment within the first three months of initial contact (Condelli & Duntemen, 1993). This high dropout rate raises concerns about how best to engage clients upon initial contact. Many clients enter into treatment feeling highly ambivalent about making changes as well as feeling guarded and vulnerable to criticism. How a counsellor engages a client often determines whether the client will succeed in treatment.
It is critical during the initiation phase that counsellors convey an attitude of understanding, respect, concern and hope toward clients. Counsellors should examine their own attitudes to their clients' subculture, which are often viewed as deviant by those who have little contact with a drug-using population (Woody et al., 1994). A non-accepting attitude by a caregiver can easily result in the client turning away from treatment.
The orientation and assessment of a client can be viewed as the first line of intervention. Whether or not a client's needs are responded to by the treatment team during the orientation process can determine her or his further engagement in treatment. It has been shown that using this client-centred approach results in superior treatment retention (Brands et al., 2002).