During treatment, all clients at the programs offered in our substance abuse agency complete a “Client Satisfaction Survey.” This survey is comprised of 14 questions — the first nine questions query the client’s satisfaction with various aspects of treatment and the respondent may choose among four responses, ranging from “Very Satisfied” to “Very Dissatisfied.”

The remaining five questions are open-ended, inviting the client’s narrative feedback. For example, respectively, Questions 10 and 11 asks the client to “list the two most and least helpful aspects of your treatment here at CAB.” For these two questions, clients are invited to use an extra page if needed. Question 12 asks if the client would refer a family member or friend to CAB.

In terms of daily client-staff interactions, these three narrative-style questions provide the best window into the client’s treatment experience. For example, in a recent Client Satisfaction Survey at our residential stabilization program for homeless men, one client responded to Question 11 (least helpful aspects of treatment) by stating: “Jane* comes into work in a bad mood and does not take time to listen to clients.” In that same set of client surveys, another wrote, “John* is not very helpful. Rob* was also being rude.” A client responded to Question 11 (most helpful aspect of treatment): “Ben the staff person. He took time to talk to me.” Another man wrote, “Lisa is a blessing to this program. You should give her a raise.”

From our detox to half-way houses to outpatient services, these responses are fairly typical — including the variance in how clients were treated. When clients complain about staff, it is generally for rudeness, impatience or their general demeanor.

When management investigates these incidences, or when a client submits a formal written grievance, the staff member usually is at fault, acknowledges responsibility, and in retrospect, wishes he or she had acted differently. Granted, these interactions are not flagrant violations of staff-client boundaries or of ethics — but they are still a cause for significant concern.

On the best-scenario end, staff rudeness will hamper the client’s overall treatment experience — it leaves a bad taste in their mouth. More serious is when a negative staff-client interaction causes a client, as an act of protest, to leave treatment prematurely or to re-think his discharge plans for continued treatment. Worst-case scenario is when the staff’s rudeness quickly escalates to a client’s administrative discharge, which in truth, was largely initiated by a staff member’s less-than-therapeutic approach.

Training staff in customer service

Four years ago, I started doing agency-wide customer service trainings, modified for human service settings and emphasizing the link between serving our clients (customer service) and better clinical care. These trainings focused on the importance of balancing rules-enforcement with treating clients with dignity and respect. Above all, and while acknowledging the often stressful nature of our environment, the trainings stressed that staff behavior should not lead to a defensive, angry response from clients. The trainings also addressed working with an angry client, emphasizing how our clients often feel physically bad, and as a result have a harder time following treatment expectations. Finally, we discussed how addicts internalize society’s bias and mistreatments, so they sometimes over-react to our usual approach. Staff members generally responded well to these trainings and left committed to being more attuned to customer service.

We certainly saw the impact on daily treatment, but the client comments about perceived mistreatment continued. Therefore a year-and-a-half ago, I began to wonder if I was missing some important dynamic, or perhaps there was another way to approach this problem?

Quiet Rage: The Stanford prison project

A prison documentary supplied the missing piece in this puzzle. Titled “Quiet Rage,” the piece profiles a 1971 Stanford University prison experiment led by social psychologist Dr. Phil Zimbardo, in which he set out to see what would happen when people are placed in an environment in which some individuals have power and other do not, and how such an assigned role could dictate and help to shape behavior.

At Stanford, the researchers created a mock prison, in which psychologically healthy undergraduates were recruited and randomly assigned the role of prison guard or of prisoner.
The team took great pains to simulate a real prison. “Prisoners” were “arrested” and then searched, showered, given prison uniforms, and jailed. Guards were also given uniforms and received instructions on how to control prisoners — including tactics to diminish their self-esteem as well as self-worth. Physical violence was prohibited.

The project, originally planned for two weeks, was discontinued after six days. Some guards overplayed their new identity and were psychologically abusive to the prisoners, while others were less comfortable with their assumed power and took a back seat. As for the prisoners, some revolted intensely against the guards and did everything possible to resist control and disobey orders. Other “inmates” became particularly compliant and assumed the role of the good prisoner who easily followed directions. The experiment was ended prematurely because it was too psychologically harmful to the participants.

Yes, but we’re not a prison

So what does a prison experiment have to do with clients in substance abuse treatment? I was so deeply inspired by this documentary that the management team and I decided to make it the centerpiece of our agency’s newly focused customer-service training.

Though it varies from program to program, there are inherent power differentials between treatment staff and clients. In the field, depending on organizational treatment philosophy, demographics or mission, that freedom-power balance varies. Some programs adapt a social model, while others use a more directive approach. Within our own agency, the clients’ freedom varies from program to program, with detox and outpatient occupying opposite ends on that continuum, half-way houses being somewhere in the middle. Typical rules are as follows:
• Clients either can’t smoke or are told when they can smoke.
• Clients are told when they can and cannot sleep.
• Clients are told when to eat.
• Clients are told when they must go to treatment groups.
• Clients are told when to get up and when to go to bed.
• Clients are told when and how much medication they can have.
• Clients are told what they can and cannot wear.
• Clients are told what possessions they can and cannot have.
• Clients are told when they can and when they cannot make phone calls.
• Clients are told when they must urinate.
• Clients are told if and when they can see friends or relatives.
• Finally, clients may not be allowed to voluntarily leave the treatment program.

Most importantly, I saw how the “Quiet Rage” documentary could quickly and poignantly increase staff sensitivity to how clients can react and respond when living in an environment where some of their freedoms have been taken away. I also wanted to heighten staff sensitivity to what can happen to them (staff) when given power and control over others — how their role can, in part, determine their behavior.

A new tack, a new training

We designed the newly focused training with three distinct steps:
1. A pre-training staff survey, which elicited staff’s feelings about their own power.
2. The staff training session
a. Introduction
b. Showing of “Quiet Rage”
documentary
c. Staff discussion
3. Post-training staff survey.

Prior to launching the new staff training, we gave staff a confidential survey in which we asked them how concerned they thought they needed to be regarding the power they have over clients and how mindful they need to be about the potential abuse of their power. The survey also asked staff if they had ever felt that they abused their power. It also asked how responsible they thought they were in determining clients’ behavior while in treatment.

After collecting and tabulating staff responses, it was then time for the actual training sessions, administered across nine programs and over a period of four months. For each group, comprised of 10-25 people, we showed the “Quiet Rage” documentary and led the staff-discussion on its implications for our client-care:
Initially, the staff was confused as to why I was using a documentary of a mock prison experiment as a training in a substance abuse treatment program. However, as the post-viewing discussion unfolded, it became clear. The discussion centered on the following topics:
• How was the mock prison different or similar to our treatment settings?
• How does staff feel about the power they have and what behaviors could that power create?
• What can occur in the treatment setting when staff members act sadistically or disrespectfully?
• What can occur in the treatment setting when staff are uncomfortable with power and instead, want to be liked by clients?
• What can occur in the treatment setting when staff is tough and fair?
• What roles may clients adapt when they have limited power and control?
• What reactions can occur in us when our authority is threatened?
• How can our reactions affect clients’ behavior in treatment?
• In general, staff’s role can promote sadism and control; clients’ roles can promote shame and confusion.
• Do we need to be mindful of our role and power?
• Finally, rules and power are necessary in all treatment programs; however, they are there not to control clients, but to maintain a therapeutic treatment environment. Also, how rules are enforced — the body language, tone and demeanor — is critically important.

Client satisfaction: The real proof

We continue to review client satisfaction surveys as a way to gauge whether clients’ concerns about staff-treatment have changed.

Transitions, the men’s residential program cited at the beginning of this article, traditionally had the highest reports of client dissatisfaction or complaints about staff rudeness. Traditionally, only 67% of clients said that they would refer a family member of friend to that program.

Following the new staff customer service training, and staff’s heightened sensitivity to power and powerlessness, the percentage who would refer consistently reaches 90 percent or above.
While there are many factors responsible for overall client satisfaction, I believe that the staff training was at least partially responsible for this change. There are also fewer narrative complaints or incidences in which a staff member is deemed "rude" or "impatient" or "not listening," "direspectful" or "unprofessional."

*In reporting client surveys, staff names changed.

Michael Levy, PhD is Director of Clinical Treatment Services, CAB Health & Recovery Services, Inc. For more information visit www.cabhealth.org.

This article is published in Counselor,The Magazine for Addiction Professionals, April 2005, v.6, n.2, pp.27-32

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