SUBSTANCE ABUSE TREATMENT SYSTEMS: FROM READINESS TO RECOVERY

At the December CRC Information Session Martha Kane, Ph. D., spoke on addictions, detox and other treatment programs, and how to offer help along the complex path to recovery.

Overview

Addiction is a complex and overwhelming disease, from which the path to recovery is not always simple. The journey from readiness to recovery has three phases, which are essential to a successful life of sobriety. Beginning with identifying and recognizing the problem, moving through assessment of readiness and level of care needed and ending with active treatment and management of relapse, clinicians have an important role in assisting patients suffering from addiction.

Recognizing the Problem

Routine screening for addictions is crucial for all patients regardless of age, income, education level or presenting problem. The easiest way to do this is to ask a single question, ’Have you ever had four (female)/five (male) or more drinks in a single sitting?’ Other useful addiction assessment tools include the CAGE, AUDIT, and TWEAK instruments, all of which are available online. Additionally, behavioral screenings are also useful in identifying a problem. Watch for dilated pupils, intense affect, missed appointments and/or chaotic life situations.

Readiness for Change: Basic Assumptions

When assessing a patient’s readiness for change, it is important clinicians remember that readiness is variable and must be re-evaluated on an on-going basis. Clinicians must also recognize that relapse should be expected and that managing motivation must include relapse prevention and management. Think of times you tried to modify your own behavior. It isn’t easy, and most people can relate to relapsing and needing to remain constantly vigilant.

Readiness for Change: Consider Motivation

When moving into the readiness phase, clinicians must remember the key to unlock behavior change is motivation. There are several basic helpful concepts for successful motivational work. The first is that an individual must be ready for change before it can occur. Just because the clinician has identified the problem with the patient does not mean this individual is (or will remain) ready to change, which can be rather frustrating for the clinician and other team members.

Remember that behavior change is a process, not an event, and is non-linear. A clinician may see a patient with addiction take many steps away from their unwanted behavior, and then suddenly return to where they were before. Patience and understanding are critical in providing support to these individuals working toward undergoing major changes in their life.

Lastly, clinicians must understand that other people and the environment play an important role in the process of change. If friends and family are also addicted it will be much more difficult for the person trying to change his/her behavior.

Beliefs Critical for Change

Advisor style is a powerful determinant of client resistance as well as change. It is critical that clinicians use accurate, genuine empathy and warmth. If these emotions are not real, patients are able to sense it and become resistant nearly immediately. Use reflective listening; adopt a curious stance; ask questions and don’t presume you know the patient’s story. It is also essential that clinicians understand that argumentation, even in a calm, persuasive manner, is a poor method for inducing change and, in fact, will activate resistance.

Process of Change (Prochaska & DiClemente)

Doctors Prochaska and DiClemente developed a process of change model in 1982, which includes five stages through which patients must travel. When using this model, it is important to understand and incorporate the use of motivational interventions, which are based on some general principles:

The general strategies in employing these principles include giving gentle advice, identifying and removing existing barriers, helping the client explore choices, decreasing the desirability of the identified behavior practicing empathy, providing supportive feedback and actively helping.

According to Prochaska and DiClemente’s model, individuals with addictions begin in the pre-contemplation stage, where the patient does not recognize the link between their behavior and the undesired outcome they are experiencing. In this stage, patients are in complete denial of the problems, which often evokes anger in clinicians. The motivational interventions to use here are education, validation, avoidance of arguments, and exploration of likely outcomes.

Availability of information is often the single factor responsible for moving the patient into the contemplation stage of change, in which individuals begin to realize they do have a problem. Because this is a stage of ambivalence for the individual with the addiction, clinicians tend to use persuasion when working with these patients. Instead, clinicians should support self-efficacy, clarify the client’s goals, weigh the pros and cons of both the behavior and change, educate and validate the patient’s thoughts and feelings. A common pit-fall is for the clinician to downplay or have difficulty tolerating examining the “pros” of continuing using substances. It is vital to give the rewards full acknowledgement and attention, as they do have a powerful impact on the client’s behavior, and to recognize the losses that success will entail.

Patients next move into the preparation stage of this process, where they accept the link between their behavior and the undesired outcome and have decided to make a change. Preparation is often minimized and devalued. It is important to recognize it as a valid stage of anticipation and planning. It is also important that the clinician help identify and gain support for the patient from others in their life.

In the next stage, action, the patient is ready to move forward with change and takes steps to do so, including active treatment. This stage typically lasts for several months during which patients must make a daily (or hourly) choice to maintain abstinence. Close monitoring and management of motivation often becomes the most important role of clinicians.

The last stage in the process of change, according to Prochaska and DiClemente, is maintenance. This is an active period where there is always a possibility, or even a probability, of backslide. Patients remain here for the rest of their life and must continually work to support their decision of abstinence, along with clinicians and other important people in their life. AA members generally have a better outcome than those not involved in self-help. Smart Recovery is also effective, though there are fewer Smart Recovery groups so a client would need to be willing to travel.

Level of Care Decisions

When a patient has moved into the action stage and is ready to engage in active treatment, a level of care decisions must be made.

There are many patient factors to analyze when making an appropriate level of care decision. These factors include the risk of acute intoxication or withdrawal symptoms, biomedical conditions and complications, emotional and/or behavioral conditions and complications, treatment acceptance and/or resistance, relapse potential, and recovery environment.

Here are some guidelines to help determine the level of care needed:

Active Treatment: Inpatient Options

Detox

This is the best choice when significant to severe withdrawal risks are present. These risks are typically associated with alcohol, opiates, benzodiazepines, sedatives, hypnotics, and barbiturates. Detox is the best choice when medical monitoring or management is required or medical conditions complicate withdrawal symptoms. Stimulants such as speed or cocaine and hallucinogenics such as marijuana don’t pose serious withdrawal risks and therefore do not require a detox stay. Detox treatment programs are for medical stabilization only and must be accessed within the first twenty-four to forty-eight hours after a patient has been seen. Minimal substance abuse treatment is offered in these programs, largely because patients are often too sick from withdrawal symptoms to benefit. Dual diagnosis detoxes are available for patients with acute psychiatric issues. Detox programs are available to insured, public payor, or Free Care patients. The West End frequently refers to CAB, Baycove, McLean, Faulkner, SSTAR, and Gosnold.

Detox Tips

Residential Care or “Rehab”

Another inpatient treatment option is residential care, commonly referred to as ‘rehab.’ These programs have a seven to ten day length of stay, depending on payment source. Residential care programs are often offered at the same setting as detox. These programs are where the active treatment process begins through the use of psycho-educational groups.

Rehab is appropriate for patients with moderate severity of emotional or behavioral conditions and for patients who need intensive motivational support to maintain behavior change (generally demonstrated by a history of failure with less intensive levels of care). Individuals are typically transferred to inpatient rehab from detox, hospitalizations, medical rehabs, or holding programs, as this type of treatment is generally not accessible from an outpatient level of care. Availability and length of stay for patients in these programs are determined by insurance, though there are some Department of Public Health funded beds. These programs are also offered at CAB, Baycove, McLean, Faulkner, SSTAR, and Gosnold.

Long-Term Residential

The last type of inpatient treatment option is a long-term program. The length of stay in these programs is usually three to twelve months. This category includes halfway houses, sober houses and three-quarter way houses. Long-term treatment programs are not accessible from an outpatient level of care with the exception of sober houses, which can be accessed from the street if necessary. These programs usually require structured daytime activities outside of the program (i.e., employment). Types of treatment provided in long-term programs include groups and on-site counseling.

Active Treatment: Outpatient Options

There are also a few outpatient treatment options for patients in the active treatment stage. Overall, outpatient treatment options are for those at low withdrawal risk. Additionally, patients must be medically and psychiatrically stable.

Partial Hospitalization or Day Treatment Programs

These treatment programs are available to patients with no withdrawal risk and no unstable medical or psychiatric conditions. They are designed to target moderate behavioral or emotional issues that require treatment, motivating, and monitoring. Patients typically participate in partial hospitalization or day treatment programs for about six hours per day, five or six days per week, for two or three weeks. Since there is a high likelihood of relapse for these patients without close supervision, a safe, supportive living environment is also imperative to successful abstinence. While these treatment programs are group based, psychiatric support, psychopharmacology, and family support services are usually available. Insurance is required for admission into partial hospitalization or day treatment programs and there are only a few Department of Public Health funded beds. Partial Hospitalizations differ from Day Treatment primarily in the availability of on-site medical care.

Intensive Outpatient Treatment Programs

Intensive outpatient treatment programs are also sometimes called Structured Outpatient Addiction Programs (SOAP’s). Patients are involved with these programs for three hours each day, and typically attend three days a week for two to four weeks. SOAP’s are available to patients with no withdrawal risk, who are medically and psychiatrically stable. These programs are geared toward individuals living in a stable environment who have mild to moderate behavioral and emotional issues who are willing and ready to maintain their own abstinence with intermittent monitoring. Treatment in these programs is psycho-educational and process group based, though other services may be available depending on providers.

Resources

Since there is a constant state of change in detox programs and the insurances they accept, it is difficult to impossible maintain a current written list. Dr. Kane recommends using one of the one of the online databases that are frequently updated, such as:

For more assistance, contact the West End Clinic: Lucy Mograss, Case Manager x 6-2712.

-Thanks to Dr. Kane for her inspirational and informative presentation and for her help with this article.

12/06