Patients ARE working hard…relapse does not equal failure!
Recovery from substance use disorders is seldom a straight line. Dr. Neff explains the importance of supporting patients on their often winding recovery paths as vital to the therapeutic process.
by Daniel Neff, MD, FAPA
The maxim “You can’t work harder than the patient” is introduced early in psychiatric training. It is concise, conveys an essential lesson about therapeutic boundaries, and provides clinicians with an easy heuristic that feels comfortable. However, when interpreted too rigidly, it can foster clinical disengagement and, at times, an unhelpful distancing from the patient—ultimately creating a new barrier to the therapeutic progress. This is particularly evident in the treatment of patients with substance use disorders.
By definition, substance use disorders involve the dysregulation and hijacking of reward pathways, making difficulty with sustained effort and consistency an expected component of the illness rather than a sign of unwillingness. Thus, clinicians should not be surprised when patients struggle to “work hard” at recovery; these struggles are part of the very pathology we are tasked with treating. A clinician who refuses to engage beyond the patient’s moment-to-moment level of effort may be undermining treatment from the outset.
Just yesterday a patient joined me for his appointment and began by sharing his recent relapse. He explained how immediately afterward he had told his (disappointed) girlfriend, shared at his regular AA meeting, and texted 20-30 members of his support system to share. I praised his forthright taking of accountability and seeking support and redirected him vigorously from his expressions of shame or failure.
He shared how he began by telling his sponsor he was going to turn in his 5 month coin. The sponsor rightly chastised him for even thinking such a thing, encouraging that “those five months are yours, you earned them, don’t you dare try to give that back.” Praising his success up to that point and reinforcing his ownership of it was far more useful and healing than accusing him of “not trying hard enough.” As the behaviorists teach: rewarding desired behaviors is often more effective than punishing undesired ones. The relapse was not a sign of his non-seriousness, but a valuable part of the learning process.
A useful non-clinical analogy (that I am enjoying again at home) can be found in the familiar challenge of toilet training a child. No parent would reasonably respond to an accident by saying, “It just seems like you’re not really trying,” and then withdraw from the training process. Instead, effective caregivers recognize that behavioral learning demands patience and persistence. They avoid blaming the child and instead function as supportive coaches—providing guidance, praise for small successes, and encouragement around setbacks. This approach acknowledges that “accidents happen” and that lapses are a normal part of learning.
These same principles apply to substance use treatment. Relapses or slips should be understood not as evidence of a patient’s lack of effort, but as signs that their work remains ongoing. Patients with substance use disorders often exert tremendous effort simply to present for treatment. What may feel like “working harder than the patient” is, in fact, the clinician fulfilling their role: to help the patient engage more effectively in the work of recovery. Supporting patients through setbacks is not exceeding one’s professional duty—it is a core element of the therapeutic process.
Daniel Neff, M.D.is a board-certified psychiatrist and addiction psychiatrist dedicated to advancing evidence-based treatment for substance use disorders. He completed his undergraduate studies in Biology at Duke University before earning his medical degree from Jefferson Medical College. Dr. Neff then pursued residency training in psychiatry at Thomas Jefferson University Hospital, followed by fellowship training in Addiction Psychiatry at the University of Pennsylvania.
Dr. Neff currently serves asMedical Director of the Mirmont Treatment Centerwithin Main Line Health and as anAddiction Psychiatrist with Mirmont Outpatient Centers. He has previously held multiple leadership roles at Thomas Jefferson University Hospital, including Associate Medical Director of the MATER and My Sister’s Place treatment programs and Associate Clerkship Director for the Department of Psychiatry and Human Behavior.
Committed to medical education, Dr. Neff has held faculty roles at Sidney Kimmel Medical College and currently serves on the volunteer faculty of the Philadelphia College of Osteopathic Medicine. His scholarly work includes peer-reviewed publications, book chapters, and presentations at local and national conferences, particularly in addiction psychiatry, psychopharmacology, and the intersection of medical and psychiatric care.
Dr. Neff is active in professional leadership and committees, including service within the American Psychiatric Association and Philadelphia Psychiatric Society, where he formerly served as Secretary. He has been recognized with several awards for teaching, humanism, and excellence in clinical care.