Chapter 4 – Addiction Treatment and Steps of Care
When an individual is struggling with an addiction to drugs and/or alcohol, the idea of long-term sobriety and recovery may seem impossible. As defined earlier, addiction is both a chronic and progressive disease that compromises an individual’s physical, psychological, and spiritual well-being through the abuse of substances. People who were once happy and productive gradually become consumed with the procurement and use of drugs and/or alcohol, to such a point that their daily activities revolve around using substances and being around other people who use.
Despite the debilitating nature of addiction, recovery is possible. However, finding help and deciding which steps to take can be a daunting experience. Some individuals and their families are exploring these options for the first time. Others have attempted to get sober in the past, only to relapse and fall back into old, familiar and dangerous patterns.
The important take-away message is that, despite any pitfalls or setbacks that may occur, the individual who is addicted to drugs and/or alcohol should not quit in their pursuit of recovery. In order to fully understand the process of addiction recovery, one needs to both understand which steps need to be taken, as well as the underlying goals of each step. It is important to note that the journey to sobriety and recovery is different for each addict—what may work for one person may not work in the same ways for another.
The Steps of Addiction Treatment and Recovery
This chapter explores the steps that are involved in the recovery process. The layout of these steps run along a continuum, from the very beginning through their completion. Again, it can’t be stressed enough that the steps outlined may not apply to everyone in recovery. However, it is important to note all of the facets of addiction treatment.
There are formidable challenges when seeking help for oneself or a loved one who is struggling with substance abuse. Sometimes, a direct, heart-to-heart conversation sparks the addict to start their own path to recovery. In other cases, this candid conversation needs a more focused approach in order to achieve the best possible outcomes. This focused approach is called an intervention.
An intervention is a carefully choreographed process that involves family, friends, and other people who are concerned about the welfare of the struggling addict. People who struggle with addiction are often in denial about their situation and can be unwilling or unable to seek help on their own volition. Additionally, an addict is not always aware of the negative consequences their behavior has on themselves and others. In the intervention process, these people will come together to confront the addict about the consequences of their addiction and ultimately ask them to accept treatment.
The intervention serves three purposes:
- Provides specific examples of destructive behaviors and their impact on the addicted person, as well as their loved ones
- Offers a pre-arranged treatment plan with clearly demarcated steps, goals, and guidelines
- Spells out what each person will do if a loved one refuses the offer to go through treatment
What are the Steps of an Intervention?
While there are differences in philosophies and the means of presentation, interventions usually involve the following steps:
- Planning—A family member or friend proposes an intervention and forms a planning group. It’s best that the group consults with an intervention professional (interventionist)—a qualified counselor or social worker—when planning an intervention. An intervention is a highly charged situation that has the potential to cause anger, resentment, or a sense of betrayal. Especially if there are concerns that the intervention may trigger anger or violent behavior, consult an intervention professional before taking any action.
- Gathering information—The group members find out about the extent of the loved one’s problem, then research the condition and treatment programs. The group may make arrangements to enroll the loved one in a specific treatment program.
- Forming the intervention team—The planning group forms a team that will personally participate in the intervention. Team members set a date and location, then work together to present a consistent, rehearsed message along with a structured treatment plan. Do not let your loved one know what you are doing until the day of the intervention.
- Deciding on specific consequences—If your loved one doesn’t accept treatment, each person on the team needs to decide what action he or she will take. Examples include asking your loved one to move out, cutting off any financial support, or taking away contact with children.
- Writing down what to say—Each member of the intervention team should detail specific incidents where the addiction has resulted in problems, such as emotional or financial issues. The goal here is to present these issues in a way that is firm, while still expressing care and concern.
- The intervention meeting—Without revealing the reason, someone from the group asks the the loved one to meet them at the intervention site. Members of the core team then take turns expressing their concerns and feelings. If an interventionist is present, he or she helps to moderate the session. The loved one is presented with a treatment option and asked to accept that option on the spot. Each team member will say what action they will take and which specific changes they will make if the addicted person doesn’t accept the plan.
- Follow-up—The continued involvement of a spouse, family members, or other close friends is critical in helping someone with an addiction stay in treatment and avoid relapse. This can include changing patterns of everyday living to make it easier to avoid destructive behavior, offering to participate in counseling with your loved one, seeking your own therapist and recovery support, and knowing what to do if relapse occurs.
The intervention must be planned carefully and meticulously. Interventions that are poorly planned have the potential to make the situation worse. It is highly advisable that the group seeks professional help with planning, through an interventionist, psychologist, or mental health professional. This is especially true if the loved one has a chance of showing up to the intervention under the influence of substances, has a history of serious mental illness, has a history of violence, or has displayed suicidal thoughts.
A crucial early step in the recovery process to consider is detoxification. The detoxification process is generally defined as a set of interventions whose purpose is the management of both acute intoxication and the withdrawal symptoms that can be experienced by an addict. Detoxification allows the body to clear out the toxins that have accumulated during the addict’s period of substance use and abuse.
The concept of detoxification can be traced back to the 1970s, when perceptions of treatment and the overall conceptualization of addiction started to change. Prior to the 1970s, public intoxication was viewed as a criminal offense. People who were arrested for this offense were held in so-called “drunk tanks” (which were cells in the local jails) and went through withdrawal with little or no medical intervention. With the advent of the disease model in our understanding of addiction, perceptions started to shift. Addiction went from being a criminal offense to a condition that needs to be treated humanely and with compassion.
Ideally, this process should be undertaken medically. Its purpose is not to resolve any underlying psychological, social, and behavioral problems associated with addiction and substance abuse. There are three objectives of detoxification and they are the following:
- Evaluation—involves testing the bloodstream to determine which substances are being abused and measuring their concentrations, as well as screening for any co-occurring mental and physical conditions that may be the underlying factors for an individual’s substance abuse. Additionally, there is a comprehensive evaluation of a patient’s medical and psychological conditions, as well as their social environment and personal relationships. From these assessments, the foundation for an initial substance abuse plan is created.
- Stabilization—includes both the medical and psychological processes of assisting the addict through their acute intoxication and withdrawal to a state where the addict is substance-free. The addict will become more familiarized with the treatment process and what their role is in that process. Family, friends, employers, and other members of the addict’s support system can become involved at this stage.
- Entry into Treatment—involves preparing the addict for entry into a substance abuse treatment program. The importance of following through and completing the entire continuum of substance abuse treatment must be stressed. For those who have completed detoxification in the past but failed to follow through with treatment, a written treatment contract may be written up in which the patient agrees to participate in a care plan.
Other Guiding Principles
In addition to the three major objectives of evaluation, stabilization, and fostering an addict’s entry into treatment, there are several principles that effectively shape the detoxification process:
- Detoxification can take place in a wide variety of settings with varying levels of intensity. Specific placement within these parameters should be appropriate and geared towards the specific needs of the patient.
- No matter what the setting or intensity level, persons who are seeking detoxification services should have access to the core components.
- All who require treatment for substance abuse should receive treatment of the same quality and thoroughness, and should be put into contact with a substance abuse treatment program after the detoxification process. These programs don’t necessarily have to be at the same location where the detoxification took place.
- Insurance coverage for the full range of detoxification services should be cost effective. If the reimbursement systems do not provide payment for complete detoxification, unwanted or unattended medical and/or social withdrawal could occur. These complications ultimately can drive up the overall cost of health care.
- Those who seek detoxification come from diverse cultural and ethnic backgrounds, and each person has unique health needs and living environments. Organizations that provide detox services must have standard practices that address cultural diversity. In addition, care providers at these facilities need to possess the special skills required to adequately provide culturally competent assessments. The administrative bodies at these facilities also need to provide the appropriate and continual training needed to address these diversities.
- Ultimately, successful detoxification can be measured in part by whether a substance-dependent individual enters, remains in, and complies with the treatment protocols of a substance abuse treatment and rehabilitation program after detoxification.
Options and Levels of Detoxification Care
There are several options for detoxification services that a recovering addict can pursue:
- Medically Monitored Inpatient Detoxification—provides around-the-clock supervision, observation, and support. This level of care is more restrictive. The underlying foundation of this option is ensuring the patient is medically stable, as well as stable psychologically and socially. Physicians are available 24 hours a day by telephone, while licensed and accredited staff oversee each patient and closely monitor their progress.
- Clinically Managed Residential Detoxification—this option can vary in levels of care: some settings adopt the medically monitored model, while others may have minimal medical oversight. In settings with minimal oversight, there should be clear procedures in place for the implementation of the detox process as dictated by the appropriate medical referrals. However, there is 24-hour supervision, observation, and support for those experiencing withdrawal or still experiencing intoxication.
- Intensive Outpatient or Partial Hospitalization Programs—these programs are appropriate for people who are experiencing moderate to mild withdrawal symptoms. Many of these programs are part of a larger hospital or linked to one, so they can provide “triage-type” services to higher levels of care if needed.
Social detoxification programs are short-term and non-medical treatment services for individuals with substance abuse disorders. These programs offer room and board for people with substance abuse issues, including those who are experiencing withdrawal. Social detoxification programs vary widely in the scope of their services: some programs offer limited medical and nursing supervision onsite, while others refer patients to clinics and hospitals for further evaluation. Additionally, there are other social detoxification programs that only offer room and board for people who are going through withdrawals “cold turkey,” or without medical assistance.
While 24-hour medically based monitoring is ideal, there are certain situations where social detoxification programs may be the only available resource. These programs are largely funded by faith-based organizations, charitable community organizations, and municipal or other local governments. Social detoxification programs operate on several guidelines, including the following:
- These programs should follow local governmental regulations, including licensing and inspection.
- People who enter these programs should be assessed by primary care practitioners that have some experience with substance abuse treatment.
- Assessments should determine the patient’s degree of intoxication, type of withdrawal symptomology, severity of withdrawals, past substance abuse history, as well as the presence of co-occurring physical and mental disorders.
- There should be protocols in place for individuals who have histories of undergoing multiple withdrawals.
- Social detoxification environments should have an alcohol- and drug-free environment with personnel who are familiar with the features of withdrawal. Additionally, these places should have access to emergency medical care and be able to provide transportation for patients needing emergency services.
Substance Abuse Treatment
Substance abuse treatment is a program intended to help people who are struggling with substance abuse issues. The goal of treatment is to help an individual stop engaging in the compulsive behaviors that are associated with their alcohol and/or drug abuse. There are many different options for treatment. Each option has a number of therapeutic and clinical protocols, and can take place in a variety of settings. Because of the complex, chronic nature of addiction, short-term and “one-time-only” approaches usually will not work. Treatment for substance abuse and addiction is a long-term process that involves multiple stages of intervention and ongoing monitoring.
In a general sense, here’s what can be expected when an individual enters substance abuse treatment at an inpatient facility. Ideally, long-term sobriety and recovery—the best possible outcomes—are achievable when individuals undergo intensive drug treatment at a facility where they will reside for a considerable period of time. The suggested length of stay that’s used as a rule of thumb is 90 days. However, that time frame can be shortened or lengthened depending on a number of factors, some of which include: the individual’s insurance concerns, how he or she responds to treatment, their drug abuse history, and the number of previous recovery attempts.
At an inpatient drug treatment program, individuals actually reside within the facility in order to do intensive work confronting any issues that have led to their drug abuse and obtaining the tools needed to overcome those obstacles. Inpatient drug treatment begins with a comprehensive clinical assessment of an individual’s specific treatment needs. This assessment is essential because it lays the foundation for an effective treatment plan that will be tailored to the needs of the individual.
Once assessment is completed, many inpatient treatment facilities have medical facilities onsite or in close proximity (such as hospitals or clinics), where immediate medical needs can be addressed. Some individuals need medical detoxification and some will need to be screened and treated for other medical conditions, such as hepatitis, HIV/AIDS, and sexually transmitted diseases, among other things. It is important to screen patients and treat other medical disorders, especially because some disorders can potentially jeopardize the health and well-being of the patient, others in treatment, and the staff.
Counseling and Therapy
In the initial phases of treatment, the main focus centers on motivating an addicted individual to stop using drugs and/or alcohol. Treatment professionals accomplish this through counseling and therapy sessions, in both group and one-on-one settings. Counseling continues throughout treatment, and the goals of these sessions are to help the individual:
- Recognize the problems caused by substance abuse
- Find the motivation to change
- Change his or her behavior
- Repair relationships with both family and friends
- Build new relationships with people who don’t use drugs and/or alcohol
- Create a lifestyle based on recovery
Along with group and individual counseling, some treatment programs incorporate behavioral therapy treatments. These methods help a recovering person to let go of their old attitudes and addictive mindset in order to embrace a new way of thinking in sobriety. There are many different behavioral therapies, some of which include:
- Cognitive-behavioral therapy (CBT) is a form of treatment examines the relationships between thoughts, feelings, and behaviors. By exploring the patterns of thinking that lead to self-destructive actions, as well as any underlying beliefs directing these thoughts, people with substance abuse issues can modify their patterns of thought and improve their coping skills. In this type of therapy, the therapist and the patient actively work together to help the patient recover.
- Family Therapy in substance abuse treatment has two main purposes. First, it uses the family’s strengths and resources to help develop new ways for the individual to live without substances of abuse. Second, it helps to lessen the impact of chemical dependency on both the individual and the family.
- Motivational Interviewing, in the scope of substance abuse treatment, is both centered on the individual and collaborative between patient and therapist. The purpose of this therapy is to elicit and strengthen motivation for change. It is an empathic, supportive counseling style that supports the conditions necessary for change—practitioners are careful to avoid arguments and confrontation, which often make a patient defensive and resistant.
- Contingency Management, also known as motivational incentives, gives positive reinforcement to motivate individuals to move away from old behaviors and attitudes centered on substance use and abuse. This is accomplished using tangible rewards.
To supplement these group and individual sessions, patients also participate in educational sessions to better understand the impact of alcohol and drugs on their brains and bodies. Counselors present lessons, lectures, and activities centered on substance abuse, often using videotapes and audio-tapes. The purpose of an educational element is to help the patients better understand the mechanisms underlying substance abuse and how they can manage it in their lives.
Another significant focus of inpatient drug treatment is the acquisition of life skills that a recovering person will need to function outside of treatment. This life skills training can include the following:
- Learning and practicing employment skills
- resume writing, interviewing, etc.
- Acquiring hobbies and leisure activities that give the recovering person healthy outlets
- The formation of healthy, proactive social and communication skills
- Anger and stress management
- Money and time management
As an individual enters the later stages of inpatient treatment and begins to discuss appropriate aftercare options, the focus shifts to relapse prevention. Relapse prevention training is designed to help people identify specific stimuli (triggers) in their day-to-day environments that might increase their risk for relapse. Patients in treatment will also learn how to deal with cravings, how to handle stressful situations, and what to do if there is a relapse.
Within inpatient treatment, some facilities orient clients towards self-help groups such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Cocaine Anonymous (CA), among others. Other treatment centers take a non-12-step approach, connecting their clients with groups like SMART Recovery and Women For Sobriety. The purpose behind introducing these self-help groups to people in treatment is to help them understand, at an early stage in the recovery process, the importance of peer support. Once formal treatment is completed, feeling supported and empowered among people who are on a similar recovery journey are essential components to achieving long-term sobriety.
Co-occurring Mental Disorders
Inpatient drug treatment also seeks to address any co-occurring mental disorders that might contribute to an individual’s substance abuse. This is called a dual diagnosis. Many people who abuse substances issues suffer from depression, anxiety, or post-traumatic stress disorder (PTSD). Adolescents who may be in treatment have behavior problems such as conduct disorders or attention deficit and hyperactivity disorders. Treating both substance abuse and any underlying mental disorders can improve the odds of long-term recovery significantly.
There are many different settings where formal treatment for both substance abuse and co-occurring disorders can take place. Each person who seeks help for a dual diagnosis has different needs and challenges, depending on the severity of their mental disorder and the role that it plays in their substance abuse. Beyond an intensive inpatient setting, there are several other options with varying degrees of structure:
- Residential treatment program—similar to intensive inpatient, but the patients themselves are responsible for the upkeep and maintenance of the facilities. The typical length of stay is 7 to 30 days.
- Halfway House—has around-the-clock monitoring by non-medical staff, or individuals who are involved in recovery and have sustained sobriety. In these programs, clients usually have a job and participate in counseling or therapy in the evenings.
- Day Treatment—uses a combination of both medical and non-medical staff to deliver a high concentration of counseling services during the daytime, allowing patients to return home in the evenings. This option can also include partial hospitalization programs.
- Intensive Outpatient—usually done in a clinical setting, patients receive approximately 6 to 9 hours of counseling services weekly. In comparison, traditional outpatient services are typically delivered by counselors in a clinical setting and provide fewer hours of service.
Once an individual has completed a formal treatment program, it can be difficult to adjust to the normal routines and day-to-day stresses while transitioning into independent living. Aftercare programs give an addict who’s new in recovery opportunities to adjust to all of these new changes, easing their transition back into a normal life with the empowerment and support that they need to stay sober.
There are several options that individuals can pursue in regards to aftercare programs following treatment. The type of aftercare that will work best depends on the individual. Some common aftercare options that are available include the following:
The primary goal of counseling in an aftercare program is to help patients identify some of the reasons for their substance abuse. This is often done in a group setting, where patients can share common experiences during the counseling sessions. Group therapy also reduces the cost of counseling, although individual sessions may be required for patients who have unique psychological issues that relate to their addictions.
The majority of drug counseling sessions take place on a regular schedule. Counseling in an aftercare program typically begins with a high frequency of counseling sessions, often on a daily basis. The frequency of these sessions typically decreases over time as the patient progresses in their recovery. Some programs even provide drop-in counseling, so a patient can come in to the office for a session during regular business hours but doesn’t need an appointment. Emergency counseling, otherwise known as crisis counseling, may also be required if a patient is at a serious risk of relapsing.
The use of counseling and therapy to bolster relapse prevention is a helpful continuation of the work that was started during drug treatment. Usually, relapse prevention counseling is based in cognitive-behavioral therapy and centers on the four types of psychosocial processes that are involved in relapse:
- Self-efficacy: a person’s ability to effectively deal with situations that carry a high risk of relapse
- Outcome expectancies: a person’s expectations about the effect an addictive substance will have on them
- Attributions of causality: a person’s belief that a relapse is caused by internal causes, not external causes—yet, this belief actually makes the person more likely to relapse when unusual external circumstances occur because they do not recognize the trigger.
- Decision-making processes: when decisions seems “insignificant” or “apparently irrelevant,” but they collectively result in a relapse.
Sober Living Environments
For someone who is new in recovery, a sober living environment is an ideal place to take the life skills they’ve learned in treatment and put them into action. It can provide a safe place while a recovering person transitions back into society. Sober living houses are alcohol- and drug- free environments for individuals who have completed treatment and are looking to continue on the path of sobriety and recovery. They are often the final transition point between inpatient care and full integration back into normal life.
Those who live in sober living houses generally can stay as long as they wish, and the residences themselves are sustained through resident fees. Most houses are privately owned and will bill directly for services, though some do accept insurance payments or even Medicaid. People at many different stages of recovery are brought together in sober living homes.
Sober living is structured to supplement the total recovery process. These environments have far more freedom and much less supervision in comparison to inpatient treatment. The people who staff these living facilities typically have significant recovery time, and many are employed by a health care facility or private organization that runs them. Because sober-living residents are all in various stages of recovery, there is consistent peer interaction, support, and accountability which can benefit everyone’s recovery.
Residents are urged to avoid friends and family who they once used alcohol and/or drugs with, or who might incite them to do so again. Sober living homes typically conduct weekly or bi-weekly drug screenings of the residents. Residents are usually required, or strongly encouraged, to attend meetings and actively work a 12-step recovery program.
Sober living homes provide a recovering addict with the kind of space they need to formulate a new sober lifestyle. But, this freedom comes with structure and rules—sober living is not the kind of residence for people who want to sit idly and “wait out their time.” With peer encouragement and support, those who live in sober living homes are able to:
- Organize a job search: Looking for employment can be easier in recovery when a support system is in place. Residents can share information about available jobs or even provide recommendations for one another. Many homes schedule time during the day when individuals are supposed to search for employment, as well as provide resources to help with resumes and interviews.
- Adjust to sobriety: In a residential inpatient program, a patient has very few liberties. If an individual is back at home, on the other hand, the prospect of making responsible decisions can be overwhelming and difficult to handle. A sober home has rules to follow, but these rules create a structure that best-prepares residents for their eventual transition back to independence.
- Arrange housing: Many residents come to a sober-living community with no other place to call home. For these people, they can begin to search for an apartment while they live in a halfway house, with lots of feedback from other residents and the staff regarding what to look out for.
- Mend fences: An important step in the recovery process is making amends—apologizing to the people an addict has harmed during their substance abuse and righting their wrongs. Within a community of fellow addicts in a sober living house, a resident had support and guidance through the process of rebuilding past relationships.
Therapeutic communities (TC) are drug-free residential settings that use a hierarchical model of treatment stages. With each stage, a resident’s level of responsibility and freedom increases. These residential settings allow for peer interaction and influence, which can help people in recovery learn to participate in a household and develop effective social skills.
Therapeutic communities are operated by treatment professionals alongside people who are in active recovery. Residents who are admitted have a history of substance abuse, as well as behaviors that have eroded their ties with family members, friends, and their communities. Many residents also have co-existing issues, such as addiction to multiple drugs, criminal activity, and mental health issues.
The average length of stays in a therapeutic community has traditionally ranged from 18 to 24 months. However, due to funding restrictions for these programs, stays have been reduced and alternatives to the resident treatment model have been created to fill the void. Fortunately, this option still remains available for people seeking recovery. Unfortunately, the duration of a patient’s stay is a solid predictor of treatment success: with a stay of just ninety days, treatment outcomes are significantly better than for patients who stay only thirty or sixty days.
Treatment in a therapeutic community is comprised of three stages:
- The first stage is the introduction to the community, its rules, and its expectations. The resident also starts early treatment, which involves a personal assessment of self, circumstances, and needs. This all occurs within the first thirty days.
- In the second stage, the primary treatment phase begins and a structured model of progression is put into place. As a resident progresses, increasing responsibilities are placed upon them, along with an expectation that their attitudes and perceptions are improving.
- The third stage is the creation of a re-entry strategy and a plan for the person’s transition back into society.
A resident is expected to follow the community’s behavioral and structural norms. These norms are reinforced with rewards and punishments, helping residents to develop self-control and responsibility. As a person progresses through their treatment, they are given increasingly important roles in the community and greater responsibilities. People in these residential programs are expected to become active role models in the process, guiding new entrants by their example. These transformations are accomplished in-house, through individual and group therapy, role-playing, and peer sessions.
Daily life in a therapeutic community consists of a variety of activities, designed to keep participants working towards new ways of thinking and living. Activities include things like house meetings, groups, twelve-step meetings, recreation, scheduled personal time, and counseling sessions. The National Institute on Drug Abuse (NIDA) outlines four main types of activities:
- Clinical Groups—use a variety of therapeutic approaches to confront significant life problems
- Community Meetings—daily house meetings and groups, which are used to reinforce house rules and the dynamics of the community
- Vocational/Educational Activities—group sessions that provide work, communication, and interpersonal skills training
- Community/Clinical Management—the use of privileges, punishments, and surveillance to maintain the physical and psychological safety of residents
Some therapeutic communities are modified to accommodate specific populations, such as women, people who are incarcerated, adolescents, people with co-existing mental disorders, or people with HIV/AIDS. Other modifications can include limited length of stays or solely “day treatment” community models, which are less intensive.