By Kelly Fitzgerald 06/22/16
Entering addiction treatment could mean the difference between life and death. That’s why it’s imperative to ask questions before choosing the right place for you.
You’ve made the life-altering decision to get sober—now what? Asking for help with your addiction can be the most vulnerable and scariest time of your life. Lucky for us, we don’t have to do it alone. Addiction treatment centers are available to help us through the hard times and set us up for success on the road to recovery. Recovery is about self-discovery and learning how to live a full life without drugs and alcohol. Like all things in life, some addiction treatment centers are better than others. How can you know which one is the best fit for you? Before you enroll in a treatment center you need to ask a lot of questions first, so you know you’re enrolling in the right place for you. Ask these 10 questions before you sign up for a specific treatment facility.
1. What is your addiction treatment goal?
This is a question to ask yourself and your potential addiction treatment facility. Why do you want to attend treatment? What do you look to get out of it? Once you know the answer, ask your treatment facility what goals they have for their attendees. What does each person achieve while in treatment and what do they go on to achieve after treatment? You want to make sure your personal goals line up with those of the treatment center.
2. What programs do you offer?
There is a plethora of different addiction treatment programs across the U.S. Each facility uses a different set of beliefs, different pathways to recovery, and different sobriety tools. It’s important to ask if your treatment center offers inpatient or outpatient programs and how long each one lasts. It’s also imperative to ask what is the driving force behind their programs. Do they subscribe to the disease model of addiction? Do they use and support the 12 steps? Are there programs for people who are atheist, agnostic, or something else? Make sure there are components that align with your personal ideals.
3. What is included in your initial assessment?
When you enroll in addiction treatment, there is always an initial assessment first. You want to know exactly what this evaluation includes so you can have a complete assessment that catches everything and anything that is going on physically and psychologically with you. This is important because these factors can determine what kind of program works for you and will affect your long-term sobriety. You want to identify any co-occurring disorders so that treatment for this can be incorporated into your substance abuse treatment. The more extensive the assessment, the better.
4. Is there a detox component to the program?
The process of detoxification can be a dangerous one. We often assume we aren’t physically addicted when we very well could be. It’s also easy to think that there is no harm in stopping the use of substances cold turkey, but there is. Withdrawal symptoms are real and depending on severity, can be extremely uncomfortable. That’s why you should ask if your addiction treatment center includes detox as a part of their program. Ask them if they have medical professionals who will safely help you get through this withdrawal period.
5. Are personalized treatment plans available?
Treatment and recovery are two very personal elements. You want to make sure the place you’re going for addiction treatment tailors each program to the person. This means they don’t just put everyone in the same boat with the exact same treatment. Humans and their experiences are unique and their environments, traumas, and psychological issues are all different. A personalized treatment plan will make sure you get exactly what you need, not what everyone else needs.
6. Is nutrition part of this treatment program?
This might seem like a side note, but nutrition is an integral part of recovery. If you’re anything like I was during active addiction, nutrition takes a backseat. I was lucky if I ate at all, let alone something that was considered healthy. In general, addiction takes a toll on our bodies and a nutritional component to recovery can help get back on track. Learning how and what to eat can put you on the pathway to success with nutrition in the future.
7. Will you take my insurance?
The cost of addiction treatment is a significant factor in almost every person’s situation. In many cases, health insurance companies can pay a large sum of the treatment program, if the treatment center is willing to work with the provider. Make sure your insurance provider offers coverage for drug and alcohol addiction treatment and then clarify with your potential treatment center that they will work with your health insurance company to reach an agreement.
8. What kind of training does your staff have?
It’s a good idea to ask what kind of training the staff at your addiction treatment center have. Ask how many doctors, therapists, and medical professionals they have on site and what their credentials are. It’s in your best interest to make sure you’re in the right hands.
9. What kind of ongoing support is available for after treatment?
We often forget to think about what happens after addiction treatment. You want to make sure you’re set up for success. Ask your treatment center what kind of ongoing support they have for after treatment. Is there an alumni program? Can you keep in contact with a certain therapist? Additionally, you’ll want to know if relapse prevention is included in the treatment program. This will provide you with the tools you need to stay sober after treatment concludes.
10. Can I stay longer if I feel like I need to?
Nothing can make treatment more difficult than leaving before you’re ready. Make sure you ask your treatment center how long their programs are and what the protocol is for staying longer if you feel like you need to. You’ll also need to check to make sure your insurance company will cover this extra time.
Entering addiction treatment could mean the difference between life and death. That’s why it’s imperative to ask all the right questions before choosing the right place for you.
Many people don’t know what to expect from addiction treatment.
By Constance Scharff Ph.D.
Posted Apr 21, 2016
There will be an extensive intake. A high quality treatment center is going to want to know a lot about you, particularly all thedrugs you have recently been using. Tell the truth. The intake staff will not judge you, but they will provide this information to the physician who is overseeing your detox. The doctor needs to know which drugs you are using and in what amounts to make your detox as safe and comfortable as possible.
Your bags and person will be searched. You’d be surprised how many people bring drugs with them into rehab. Your bags and person will be searched to keep all individuals in the facility safe.
Privacy is limited. Though you might think you’re going to have a lot of alone time, that’s not how addiction treatment works. Your days will be tightly scheduled, packed withpsychotherapy, exercise, adjunctive therapeutic activities, meditation, and so on. If you share a room, which most people do in treatment, you will not find a lot of time to yourself. This change will take some getting used to, but the good news is that with group activities comes support.
There is little down time. Treatment is not a vacation. You will not have hours to sit by the pool, write in your journal, or take strolls along the beach. There is some time for those activities, but most often, you will be engaged in therapeutic activities designed to help you overcome your addiction. That said, weekends, when most professional staff like therapists and doctors are off, can be less scheduled. Use that down time to rejuvenate and take care of yourself.
You will be expected to follow rules. Addicts are some of the world’s elite rule-breakers. In treatment, you will be expected to conform to the facility’s rules. The more you follow the rules, the more you will earn privileges and the more you’ll get out of the treatment experience. The more rules you break, the more restrictive most institutions become before finally asking an individual to leave.
High end treatment centers will be comfortable. If you pay for luxury, you will get it. The high end treatment centers offer organic gourmet food, regular massages, and top-notch hotel-like accommodations. Some have concierge services that will bring a hairdresser or manicurist in to pamper you. In a few facilities, residents can even bring a small dog. But remember, rehab is still an addiction treatment experience, not a luxury hotel, and while comfort may help by keeping you from being distracted, your purpose in treatment is to overcome your addiction.
You have an incredible opportunity to change your life. Most people who need addiction treatment never get it. Those who do may have only one opportunity to go. Take advantage of everything available to you. Rehab is your chance to change your life. Take it!
By Kelly Fitzgerald 07/04/16
I was too proud, too stubborn, and my ego was too big. If I could go back, I would go to rehab with bells on. I’ll explain why.
sober for 3 years, treatment is readily available and help is out there, but most people never ask for it.
At the time I knew addiction treatment existed, but I was terrified of going or even considering the possibility. If I could go back, I would go to rehab with bells on. I’ll explain why.
1. I wouldn’t have been so lonely.
At the beginning of my sobriety I felt extremely alone. Addiction is a very isolating disease. During my first year of my sobriety, I was pretty much the only sober person I knew. Because I was too stubborn to go to treatment I missed out on connecting with others who have been through the same situations I’ve been through. I didn’t have the chance to really connect with others in early sobriety, for that reason I still felt extremely alone.
2. I would have gotten answers.
Like everyone in early sobriety, I was a mess. I was hurt, confused, and overwhelmed by a variety of different emotions. I didn’t know whether what I was feeling was normal or not. I was vulnerable and scared. Going to treatment for my addiction could have given me a lot of the answers I was looking for. Was I going to be okay? Was it normal to feel that way? How do I do this thing? With addiction professionals and peers who are going through the same thing, a stay in rehab could have helped me answer these questions.
3. I could have talked face-to-face with therapists.
Therapists and addiction professionals exist to help people like me. Unfortunately, I deprived myself of this help. I didn’t believe I needed face-to-face help at the time I got sober, but now I know that I could benefited from it greatly. Being able to communicate with someone who is trained in helping you cope with your addiction issues is imperative to getting better. These therapists could have helped me endure those first grueling months of sobriety. They could have taught me healthy coping mechanisms.
4. I could have heard of the war stories of others like me.
One of the most powerful components of my recovery is hearing other people’s stories and sharing my own. In my first year of sobriety, I read a lot of books about drinking, including memoirs. Hearing those stories really resonated with me, but it was nothing like hearing them in person. When I finally began to attend 12-step meetings I loved the speaker meetings where real people shared their experience, strength, and hope through stories. Still to this day, it’s the type of meeting that I can relate to most. If I had gone to rehab in the beginning I could have heard more of these stories from the start and may have healed at a quicker rate.
5. Someone could have explained to me what the 12 steps were.
During my first months of sobriety I was too terrified to even go to a 12-step meeting. I was ashamed and couldn’t face people in real life, and I didn’t know what to expect at a meeting. I tried attending a few meetings online in chat rooms, but I didn’t understand what anyone was talking about or what literature they were referencing. Eventually I quit those. If I had spoken up and gone to rehab, I would have had someone explain to me the 12 steps, how they work, and what the meetings are like. This could have eased my fear about attending them in the future.
6. I could have detoxed in a safe way.
I don’t know if my body was physically addicted to alcohol. I say that I don’t think it was, but I definitely remember experiencing some withdrawal symptoms days and weeks after quitting. I felt exhausted, slept badly, felt bloated, sick, and depressed. It was only after I began to learn about addiction and withdrawal that I realized that’s what I might have been experiencing. Going to rehab would have given me a proper diagnosis and medical treatment if needed. Detox could have helped me rid my body of the harmful substances I was using and set me on the path to recovery under safe medical care.
7. I could have explained better what was happening to me.
Being without answers for the first year of my recovery left it difficult for me to explain myself to others. I was open about my sobriety from the beginning and I told my family and friends I was quitting. Some of them understood, others did not. Had I known more about the disease of addiction, how it progresses, and how it is treated, I could have passed this information onto the important people in my life. After a lot of research and writing myself, I am now better equipped to explain addiction.
8. I would have had camaraderie from the beginning.
For those of us in recovery we know that connection is incredibly important. I didn’t understand how important it was until I started attending 12-step meetings 1.5 years into my sobriety. Women rallied around me, loved me, were there for me, and I finally began to understand the word camaraderie. I also began connecting with other sober bloggers and forming a sense of community online. This component of camaraderie is one I’ve incorporated into my recovery program that I wish I could have gotten from heading to rehab when I first made the decision to get sober.
Rehab offers us a bridge between addiction and recovery. It can be the help we are so desperately seeking, but are afraid to ask for.
family, I did not know if the ruins in my wake could be cleaned up. I did not know if those bridges could ever be repaired.
I soon realized, however, that rebuilding family relationships was not just about cleaning up the mess. No matter how much I wanted to do so, I could not repair those bridges on my own timeline. Rather, I needed to provide them with evidence that I had changed by learning to be a positive and productive member of my family. I needed to develop patience in order to respect the individual forgiveness process of each family member in relation to my recovery. In truth, back in the day, patience wasn’t really my thing. I did not like it, and I still don’t. I want what I want and I want it now, but such an attitude proved to be quite detrimental both in early sobriety and in practically every other facet of life.
As I continued to make progress in early sobriety, the old demons of past behaviors and the lingering presence of my character defects led to new difficulties. By removing the drugs, my best friend and my number one coping mechanism, I was placed in a very difficult position. The old emotional triggers related to my family became inflamed as my new resentments popped out of the woodwork. By using the emotional tools and approaches discussed in this article, I was able to avoid the pitfall of generating more damage. Even more importantly, I found a way to slowly rebuild the family relationships that I so deeply valued. A key for me was to remember to take it slow.
1) Begin With The First Circle By Forgiving Yourself
Do you know how hard it is to forgive somebody who hasn’t forgiven themselves? If you want your family to see the new you, you need to stop punishing yourself for the past. If you punish yourself in the presence of your family, you will not to be a terribly fun person to be around. Resentment against yourself tends to breed resentment, and this dangerous cycle needs to be avoided in early sobriety. If you let it, your resentment of yourself will become their resentment. So, stop it early.
First and foremost, embrace the process of forgiving yourself. Picture in your mind the image of a stone thrown into a body of still water and see the resulting circle of ripples. The first circle contains you and your higher power, the second circle contains your loved ones and your family, the third circle contains your friends and associates, and onward and onward until the entire universe is included. It is important to remember that you and your higher power are the first circle.
Whatever resentment and anger you are holding onto in the first circle will spread out and affect all of the others. By not dwelling on past mistakes and forgiving yourself, you can avoid this contagious engine of negativity rumbling from within. There is no question that your family and loved ones want you to forgive yourself. It doesn’t mean they want you to forget what happened and pretend like everything has always been hunky dory. They don’t want you to minimize what happened, but it does mean they want you to be a loving and positive member of your family moving forward. The best way to be that kind of family member is to start by forgiving yourself.
2) Saying "I’m Sorry" Repeatedly Is Not A Living Amends
If you are part of a 12-step program and you are working the steps with a sponsor, it’s important to go in order and not jump ahead. There is a reason why the amends process comes after the higher power connection, the taking of inventory and the addressing of the character defects. By jumping ahead to the process of making your amends, as outlined in Step 8 and Step 9, you are subverting a process that has been proven to work effectively over and over again. It’s always best to trust your sponsor and listen to his or her suggestions.
In terms of the amends process, here is the written description of Steps 8 and 9 as detailed in the Big Book of Alcoholics Anonymous:
Step Eight: Made a list of all persons we had harmed, and became willing to make amends to them all.
Step Nine: Made direct amends to such people wherever possible, except when to do so would injure them or others.
Until you get to these steps with a sponsor, it’s best not to make amends. At the same time, when you are rebuilding your family relationships, it’s important to keep in mind, even at the beginning of the process, the concept of living amends. A living amends is distinct from a specific amends. As opposed to paying someone back or taking a particular action, a living amends means a change in behavior and bearing over time. You learn how to live differently, bringing about a genuine change in day-to-day behavior instead of one more verbal apology.
By embracing a living amends, not only do you take on a whole new way of life, but you allow that way of life to be demonstrated through your actions. A living amends is not just about saying you’re sorry to your family once again. How many times have you apologized in the past when you were living in your disease? How many times did such apologies have nothing behind them beyond manipulation? How many times did you fail to back up an apology with an action?
Rather than say sorry once again, perhaps triggering a negative response from your family as they relive the empty shells of your past apologies, change your behaviors. Do the dishes after dinner, and be of service to your family. Go on a walk with your mom, then offer to pick up the dry cleaning. Listen to what each family member has to say, and be positive in your responses. Do your best to avoid falling into old behaviors. By demonstrating to your family that you have changed through new behaviors, the rebuilding will begin to happen.
3) Don’t Measure Their Process By Your Yardstick
When I first got sober, I expected my family to stand up and start clapping when I entered the room. After all, hadn’t I accomplished something amazing? When they failed to react in such a fashion, I became angry. Why the heck weren't they acknowledging the incredible changes that came with my sobriety? When I told my sponsor about my feelings, he said that I was measuring the process of my family’s forgiveness by my own yardstick. In the past, I always thought that my yardstick was the only one that mattered. The zeitgeist of my grandiosity was that you should follow my measurements and do everything according to my calendar.
Once again, I was ignoring their process and not taking into account that forgiveness takes time. The more damage you did to your family, the longer it may take to earn back their trust. Your family might need to see substantial progress before they will be willing to forgive what happened in the past. For several years, my older sister would not let my nephew drive in a car with me. She simply was not willing to take the chance, and I had to respect her wishes.
By giving your family the same freedom that you desire and respecting their process, you will reduce the possibility of creating new resentments and open the door to true healing. I admit that finding such patience within can be hard and can even seem unfair at times, but such are the consequences of all the damage that you did in the past. I know from experience those consequences will pass if you give your family time to trust and believe in you again.
4) Learn How To Listen Without Having To Explain
As a person with the disease of addiction, I became an expert at explaining away whatever I did; a true master of rationalization. Even in early recovery, when negative aspects of my past were brought up, I would do my best to explain them away. After all, there was a context involved, and without understanding that context, how could you ever truly understand me and why I did what I did? In response to this attitude, my sponsor would shake his head and tell me to stop talking. Maybe it was time to learn how to listen first without always having the quick draw of an explanation ready to be fired.
When I did listen, I came to understand that my family had something to say. By being able to express their feelings to me about what happened and what was happening now, my parents were able to connect to their own process in relation to my recovery. They actually did not want another explanation, and any explanation coming out of my mouth, no matter how justified and contextualized and insightful, would have been detrimental to their process.The needed to express their feelings to me aloud without having to hear a response, no matter how justified I thought it was
By learning how to listen without having to explain, I helped them almost as much as I helped myself, and that became a real asset in the process of forgiving myself.
5) Be Tolerant Of And Quiet About Their Character Defects
Perhaps one of the strangest ironies of working the 12 Steps is that once I started to take catalogue of and carefully examine my own character defects, I began to see them all over the place in the actions and behaviors of other people. Since I am related to my family, both from a genetic and an environmental perspective, I grew up with them, and many of my character defects are reflective of their own. Moreover, when it came to their traditional character defects that had nothing to do with me but had always got under my skin in the past, I saw and heard them blaring like a racing fire truck on a city street. I wanted to point them out like an excited little kid.
After all, since I was working on character defects, shouldn’t they be working on their own problems as well? Wouldn’t it be helpful if I used my new sober insight to point out what they were doing so they could begin to change? When I asked my sponsor, he actually began laughing. He asked me whether I wanted to rebuild my family relationships or get thrown out of the house?
Given my obvious answer, he suggested that I learn how to be tolerant of and quiet about the character defects of my family and loved ones. They weren’t in 12-Step programs, and they weren’t asking for such feedback. Even if their character defects got under my skin, it was not my job to point them out and cause unnecessary conflict. Instead, I should keep quiet, practicing the principles of tolerance and compassion. After all the damage I had caused in the past, it was not my role in the family to suddenly become the enlightened and insightful soul that points out the faults of others. If I took on such a role, I would be embracing a deep hypocrisy while grating on and exasperating my family at the same time.
6) Accept the Reality Of What Cannot Be Repaired
I honestly wish everything could be magically fixed in sobriety and every addict could be forgiven and every family healed. Although a beautiful hope, such a sentiment is also a fairy tale.In early sobriety, I needed to accept the reality of what could not be fixed. Some of my past relationships had been broken beyond repair. This happened to me not with my nuclear family, but with some cousins and some old friends. I simply had gone too far, and they did not feel safe around me, regardless of my newfound sobriety. In many cases, the friendships had been broken long before I ventured into the darkest depths of my addiction. I was hoping to rebuild them now that I had found the path of sustainable sobriety, but this was simply not to be.
Yes, it was a hard pill to swallow, but I needed to respect the other person's decision to part ways by giving them space and leaving them alone. While you may want to attempt to reconcile even after they have turned their back on you, it is often best just to let the person be. I found it incredibly hard to accept such a reality, but I also found it to be much better than the alternative of doing more damage. Time and time again, I have seen that it is a mistake to try to force my way back into someone’s life like a bull in a china shop. One day, they might be ready to talk and reconnect. That is still a possibility years later, but in order for that to happen, I needed to respect their initial wishes and let them go.
7) Believe In Your Heart The Process Is As It Should Be
When something doesn’t go my way, when the world doesn’t fall into place in the manner that I think it should, I have a historical tendency to embrace bitterness, become really resentful, and look for an easy way to escape those negative feelings. In early sobriety, everything is not going to go your way, and I promise you that there will arise a number of sudden challenges and unexpected difficulties. This is particularly true when it comes to the project of rebuilding family relationships. In order to avoid falling back into old patterns of behavior, you need to believe in your heart that the process is as it should be.
The key to opening the door to this belief is the Third Step:
Step 3: Made a decision to turn our will and our lives over to the care of God, as we understood Him.
When I turn my will and my life over to the care of God, as I understand my higher power to be, then I let go of being in charge and having things go exactly as I want them to go. Although I often dream of the ambitions and desires of my life falling perfectly into place, they rarely do. Nothing is ever perfect, and rarely is anything even close to perfect. However, my spiritual progress allows me to avoid the pitfall of perfection and value the progress being made. Like the Beatles, I just let it be.
When I look back at my efforts to rebuild my family relationships, it actually went so much better than I ever could have expected. After never wanting to see or hear from me again, they embraced me back into their homes and their lives. Considering the damage that had been done during my addiction, this was nothing less than a miracle.
Still, in the stillness of facing each family member and their individual fears and resentments, it’s important to understand that the process differed with each one. Some were definitely quicker than others to forgive, and some will probably never be able to completely let go of the bad feelings caused by all the wreckage I left in my wake. Yet, today, I don’t have to tie my identity to those ruins. By believing in my heart that the process is as it should be, I can celebrate my present reality while remaining hopeful about the future.
8) Know That You Deserve Love And Will Be Loved
It seems obvious, doesn’t it? Every human being in this world deserves love, and everyone should have the faith that one day they will be loved in the manner that they deserve. For an addict in early sobriety, however, the idea that I am deserving of love can seem like an alien concept. In my first months and even years, I often felt forsaken, and it was so very hard to be kind and gentle with myself. By embracing love and forgiveness in the first circle between me and my higher power, everyday life became that much easier to navigate.
But it wasn’t easy. When I was out there in the depths of my disease, I believed that God had forsaken me, and if I had been forsaken, I was going to be the most forsaken bastard on the planet. I used this thought as a justification to celebrate the dark extremity of my life. In recovery, I realized that God never turned his back on me: Rather, I turned my back on God. The loving arms of my higher power were always open if I was just willing to take the first step.
A big part of taking that first step is believing that you deserve love and one day you will be loved. Such a belief goes a long way in the process of rebuilding family relationships in early sobriety. By believing that you deserve love, you actually become that much more lovable.
Even Bill Wilson advocated for a methadone analogue for alcoholics so that "lost sheep" would have a medication-assisted way of progressing in AA and completing the 12 steps.
By Jordan Hansen 05/02/16
So, we know recovery involves pretty people and sunsets, but what else is recovery? If I stop sharing needles and start carrying naloxone and using safer injecting practices, is that recovery? If I have improved connections in all of my relationships and emotional regulation, and I'm using Suboxone or methadone, is that recovery? If I go from using IV heroin to smoking weed all day, is that recovery?
I don't think it matters how we feel about any of it. I am more concerned with how our ideas affect our clients and their perceptions of behavior. Too many times the clients I work with—especially opioid addicts using some sort of agonist medication—feel that what they are doing isn't "real" recovery. Mainly, they feel this way because they are told this explicitly lots of times by people who should know better.
I have recurring experiences with treatment providers who, for the life of them, cannot make sense of somebody being both in recovery and on Suboxone. The enmity that exists between them and their colleagues who advocate treatment via medication therapies does nothing to advance the treatment of alcoholics and drug addicts, only the egos of those involved. The arrogance in the idea that the answer is here, today—that the current treatments we have for addiction are somehow good enough—is troubling.
I came across this anecdote as told by one of the originators of Methadone Maintenance Treatment in a lecture series. Vincent Dole, a nonalcoholic trustee of AA, had this to say:
“At the last trustee meeting (of AA) that we (Vincent Dole and Bill Wilson) both attended, he (Bill Wilson) spoke to me of his deep concern for the alcoholics who are not reached by AA, and for those who enter and drop out and never return. Always the good shepherd, he was thinking about the many lost sheep who are lost in the dark world of alcoholism. He suggested that in my future research I should look for an analogue of methadone, a medication that would relieve the alcoholic’s sometimes irresistible craving and enable him to progress in AA toward social and emotional recovery, following the Twelve Steps.”
I'm just going to leave that "always the good shepherd" part for another post, but I have no reason to doubt the veracity of his claim regarding Bill's hope for those not helped by AA. I am consistently dumbfounded by the dogmatic reaction of people who claim adherence to a program which, in my mind, is based on non-conformity and freedom of thought. I mean, Bill did LSD and thought niacin might be a cure-all for addiction. This is what this movement was founded on, a willingness to continue to seek new ways of fighting alcoholism. I'm especially saddened by what appears to be the willful lack of knowledge around the treatment of opioid addiction relative to abstinence. I mean, the science is in. Anecdotes aren't enough.
Suboxone has been described in my community by clinicians and owners of sober housing and other ancillary services as “a scourge.” I have listened to a room full of people who accept money—lots of it, I might add—from people who are taking Suboxone, argue with psychiatrists who were presenting data on relapse and addiction. The clinicians were sharing how lives are being saved by combining traditional therapies related to the 12 steps and MAT and how a new paradigm is needed to help stem the tide of heroin addiction. The data was met with anecdotes from the crowd about how it didn’t work for them, or how it creates issues in the sober houses they own. All of this was spoken with a disdain for a new approach, like it was somehow a threat to recovery as a whole and that these people were the last defense of the purity of the program. So be it.
It is time that those of us in the abstinence-based community attempt to make amends for our arrogance and stubborn resistance to what is now an avalanche of proof that MAT works. I was one of those practitioners. I questioned the use of buprenorphine as a counselor at Hazelden. I became angry when people would suggest that our treatment was hurting our clients. I remember distinctly being in a presentation focused on informed consent where the data on recovery rates from opioid addiction were presented dispassionately, but bluntly. I asked the presenter if he thought there was room for abstinence-based treatment for opioid addiction. He responded that there was, but likened it to using alternative treatments for cancer. After swallowing a fair amount of pride with the unhealthy dose of anger our interaction produced, I asked him to lunch. I was floored. And I was changed forever.
I find that I want to justify my actions by telling the rest of my story, but I don’t think that this is the time. The justifications, the good intentions, even actual positive results are not enough. The reticence to accept that we were wrong needs to be addressed in the entire community. It’s like we want to change everything but refuse to acknowledge that we corrected course. This is the price for continuous improvement, and it is so much more important than our egos. I’m sick of going to funerals.
I’m sick of seeing the families of young addicts decimated by what could have been avoided. I’m sick of the enmity between the “camps,” and yet I understand it. I have lived it—both sides. I am hopeful, however. I have met the next generation of both clinicians and recovering individuals. It seems to me that they have a freedom of thought and an intellectual humility that doesn’t seem to be as common in their older peers. They recognize that there are different paths to recovery, and maybe most importantly, they seem to realize that more will be revealed.
Jordan Hansen is an experienced clinician, speaker and writer focused on integrating the science of cutting-edge treatment modalities with the wisdom found in peer-supported approaches to recovery. His approach is based on authenticity, interpersonal connection and a steadfast focus on person-centered, evidence-based interventions. His experience within residential, long-term and outpatient levels of care is informed by his background in journalism, vocational counseling and non-profit management. Areas of recent focus include assisting in the design and implementation of Medication-Assisted Therapy for opioid addiction, policy work with the MN state legislature, distribution of naloxone kits to local opioid addicts at risk for overdose, and artistic and literary efforts aimed at sharing his experience with long-term recovery from addiction and mental illness. He is a graduate of the Woody Guthrie Academy, The University of Saint Thomas and The Hazelden Graduate School.
Substance use disorders are an issue of significant concern within the United States. In a survey conducted by the Substance Abuse and Mental Health Services Administration (2013), it was determined that approximately 24.6 million individuals, 12 or older, were currently using illicit drugs, including 2.2 million adolescents. They also found that an estimated 60.1 million Americans, over the age of 12, reported binge drinking within the previous month. Of the 22.7 million identified as needing treatment, only 2.5 million received treatment from a specialized facility.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Addition (2013), DSM-5, describes substance use disorders as a set of cognitive, behavioral, and physiological symptoms with an underlying change in brain circuits that may be maintained beyond the period of detoxification. These changes in the brain may result in repeated relapses and intense cravings that are tied to exposure to drug-related stimuli. The DSM-5 also indicates that the impact of the substance abuse can be persistent, requiring long-term approaches to treatment. Substance use disorders are diagnosed based on the presence of pathological patterns of behavior that result from the use of the substance, including:
Impaired control over the use of substances
As a result of the use and abuse of drugs or alcohol, the life of an addict can feel chaotic, out of control and overwhelming. Decisions are made as reactions, impulsively and with extreme behavioral responses. There is little to no moderation or regulation of behavior or emotion, and the person struggling with addiction will engage in unhealthy behaviors to seek pleasure or escape discomfort. These impulsive and compulsive behaviors will occur regardless of their consistently negative outcomes.
As the disease of addiction has such a devastating and persistent affect on a person’s life, overcoming addiction requires intensive, ongoing intervention, often including a residential treatment component. While in a residential treatment program, a patient is provided with the opportunity to escape from external factors that contribute to, and trigger, the unhealthy thoughts, feelings and behaviors that drive addiction. Within this controlled and structured environment, the patient is exposed to healthy strategies for coping and living in sobriety. In the process, he or she is taught to recognize the internal and external experiences that drive the desire to use the addictive behaviors, while learning and practicing the skills and tools that may help manage high-risk situations. The person will learn and practice behavioral, cognitive and affective coping skills, while insulated from the triggers within the community, with immediate access to therapeutic resources.
While residential treatment provides an opportunity for patients to maintain abstinence as they learn and practice the use of healthy coping skills and tools that can support a sober lifestyle, the transition back out into the community often leaves the patients vulnerable to falling back into unhealthy thought and behavior patterns that maintain addiction. In a study conducted with chronic opioid dependent patients transitioning from inpatient care to outpatient treatment, after 90 days from the time of discharge, only 22% of the patient remained in aftercare treatment and less than 3% were verifiably abstinent from opioid use (Davison, Sweeney, Bush, Correale, Calsyn, Reoux, Sloan, & Kiviahan, 2006). This lack of follow through with outpatient treatment and the high potential for relapse (Gerhardt, Breitschwerdt, & Thomas, 2015; Nordfjaern, 2011) are a distinct reality of the transition from more restrictive to less restrictive levels of care. These early stages of recovery are a time of significant vulnerability for patients in recovery, and there is a significant need for consistent support to help them maintain sobriety. In fact, research suggests that patients do not begin to experience the benefits of treatment until they have received approximately three months of care, and that patients should engage in six to twelve months of non-residential treatment in order to make stable gains (Kellogg & Tatarsky, 2012).
Relapse may be understood as the process by which a person in recovery engages in the unhealthy cognitive, social and behavioral patterns that existed prior to treatment, and potentially leads to a return to active use of drugs or alcohol. It is often the result of a combination of personal, family, social or treatment related factors, including:
The susceptibility to relapse, along with the recognition of addiction as a brain based, chronic condition is resulting in an increased awareness of the need to move away from treating addiction with acute intervention practices and to utilize a longer-term treatment model with seamless transitions to levels of care that are consistent with the severity of the patient’s condition (Tamasi, 2015); but our medical system has not adjusted to support this need. Our system of care continues to treat substance use disorders as acute conditions, with time-limited interventions and a push for rapid discharge. In addition, the transitions from one level of care to the next are often disjointed and inefficient. As a result, treatment often falls short of meeting patient needs and risk of relapse is elevated. Adjustments need to be made within the treatment system to more effectively support our patients in the earlier stages of recovery, when they are most vulnerable and in need of stronger supports.
In part, the responsibility for improving the process of treatment transitions falls on the residential and inpatient treatment programs. As the immediate re-exposure to ongoing unhealthy life circumstances (e.g. exposure to drug availability, peers and family that may not support sober living, interpersonal conflict, unstructured time) may play a significant role in the process of relapse (Jason, Davis & Ferrari, 2007), programs must have a solid understanding of the risks patients will face once the shift to community based treatment occurs. This knowledge may be used to more effectively support the patients’ needs as they move into lower levels of care with less structure and active support.
While most of these programs incorporate planning for life after residential treatment, the lack of structure and readily available support that are provided within residential treatment, leaves even the most highly motivated patients vulnerable to relapse following discharge from treatment. As such, it is essential that patients transition into environments that support sobriety and offer readily available resources that may be accessed when a patient feels vulnerable or at risk of relapse. This need can be supported with effective discharge planning and care coordination focused on the home and work environments, support systems, and outpatient treatment.
Home and Work Environments
The home environment should be evaluated with patients, prior to discharge, exploring the risks associated with the return home and to evaluate how the patient may function in a healthy way after discharge. If the risks are determined to be beyond the patient’s ability to manage, alternative arrangements might be considered. It may be of benefit for the patient to enter into a sober living home to ensure a drug-free environment is maintained and tools are in place to reinforce personal accountability to stay sober. If these resources are not feasible or available to the patient, programs may help him or her identify alternative resources that might support access to and maintenance of a sober living environment.
Interpersonal dynamics should also be considered prior to discharge, evaluating whether or not the family is able to provide the support needed to ensure the patient is able to maintain a sober lifestyle. It may be determined that the family would benefit from additional support as they adjust to having the patient back in the home. Ongoing supports, such as individual or family counseling and community based support groups (i.e. Alanon), may be of significant value to families as they struggle to overcome the damage done by the addiction, and to provide tools and skills for maintaining healthy relationships with a family member in recovery. The use of these resources should be encouraged while the patient is in residential treatment, in order to ensure that the family system has time to heal (as much as possible) prior to discharge and that they all have support once the patient returns home.
Another factor that may be considered is the significance of establishing a balanced lifestyle once the patient has returned home. Establishing a healthy lifestyle can play an important role in managing stress and helping patients avoid the risk of relapse (Jackson, 2014). Establishing a schedule with patients, prior to discharge, that incorporates exercise, work, treatment, recreation, and attendance of support groups, may be of value. Patients need to be encouraged to develop positive habits in place of the unhealthy behavior patterns that they utilized prior to entering treatment.
Recovery in isolation does not offer a recipe for success, especially in early recovery. In order to maintain sobriety and recovery, patients will need a solid support system once they have left residential treatment. They cannot return to a network of friends who have maintained a lifestyle that revolves around the use of drugs or alcohol. Instead, these patients will need to establish a social group that is supportive of sobriety. Patients may choose to look toward the recovery community, those people who are actively working to maintain their own sobriety and support the sobriety of others, connecting through community based support groups such as AA or NA. Other resources (i.e. personal recovery coaches, sponsors, employers, personal friends, etc.) may be explored with patients prior to discharge to help establish a support system that would be available when they need to reach out for help.
The coordination of outpatient treatment is another component of care transitions that is essential in supporting patient recovery. As these early stages of recovery are a time of substantial risk, and patients are returning to the stressors and life events that were associated with their use of drugs or alcohol, it is of significant importance that the patients have access to therapeutic support as soon as possible following discharge from residential or inpatient treatment. In order to effectively and efficiently ensure the availability of these supports, residential programs should strive to discharge patients with appointments prescheduled for admission to outpatient programs, preferably with an intake occurring on the same day of discharge from treatment. This expedited transition may help to reduce risk of relapse.
When establishing outpatient treatment for the patient, the residential provider may take additional steps to support a more effective transition. When establishing outpatient treatment, the residential provider should also consider any additional clinical needs, such as co-occurring psychiatric or medical conditions, and be sure to make appointments with providers best suited to meet these needs. They should also reach out to the new treatment providers to ensure that they are informed of the patient’s clinical condition in order to offer support that will best meet patient needs. Another tool that may be useful in helping patients effectively transition to outpatient treatment is to call and email the patients to remind them of scheduled appointments and to follow up after the appointments to confirm that the patient made the appointment. It may also be of benefit to intervene with the patient prior to discharge. A program in the UK found that a single motivational therapy session, prior to discharge, led to an almost 50% increase in the show rate for an initial outpatient appointment (Jackson, 2014).
Recovery can be a daunting and overwhelming process, demanding consistent and sufficient resources to ensure the best opportunity for success and sobriety. In this process, treatment providers are in a unique position to provide direct support when patients are with them, but their responsibilities do not end when patients discharge. The commitment to support patient success and wellbeing is maintained as patients move between higher and lower levels of care. There is an obligation to ensure that patients are not left without resources and support once they leave residential care. It has been well established that this transition period is a time of vulnerability with significant risk of relapse. As such, residential treatment providers must ensure that every effort is made to create a smooth and effective transition with resources and support systems prepared and established prior to discharge.
American Psychiatric Association (2013). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Addition. American Psychiatric Association: Arlington, VA
Davison, J. W., Sweeney, M. L., Bush, K. R., Correale, T. M. D., Calsyn, D. A., Reoux, J. P., Sloan, K. L. & Kiviahan, D. R. (2006). Outpatient treatment engagement and abstinence rates following inpatient opioid detoxification. Journal of Addictive Diseases 25(4) 27-35
Gerhardt, U., Breitschwerdt, R. & Thomas, O. (2015). Relapse prevention in drug addiction: addressing a messy problem by IS action research. AI and Society 30(1) 31-43
Jackson, B. R. (2014). An overview of the relapse prevention (RP) model. Journal of Addictive Disorders. Retrieved October 14, 2015 from Breining Institute at http://www.breining.edu
Jason, L. A., Davis, M. I., & Ferrari, J. R. (2007). The need for substance abuse after-care: longitudinal analysis of oxford house. Addictive Behaviors 32 803-818
Kellogg, S.H. & Tatarsky, A. (2012). Re-envisioning addiction treatment: a six point plan. Alcoholism Treatment Quarterly 30(1) 109-128
Nordfjaern, T (2011). Relapse patterns among patients with substance use disorders. Journal of Substance Use 16(4) 313-329
Substance Abuse and Mental Health Services Administration (2013). National Survey on Drug Use and Health: Overview of Findings. Available at: http://www.samhsa.gov/data/sites/default/files/NSDUH-SR200-RecoveryMonth-2014/NSDUH-SR200-RecoveryMonth-2014.htm
Tamasi, R. V. (2015). Why we must redefine addiction treatment. Behavioral Healthcare 34(3) 21-23