Treatment

Treatment enables people to counteract addiction and mental illness’ disruptive effects on their brain and behavior to regain control of their lives.

There is no cure for addiction or mental illness, however, through evidence-based therapy — often combined with medication — a person can identify and change troubling emotions, thoughts and behaviors. The goals of this therapy is to gain relief from symptoms, maintain or enhance daily functioning and improve one’s quality of life.” [1] 

In other words, learn to manage the disease so it doesn’t manage you. 

Formal treatment at a reputable facility typically incorporates a combination of detox, behavioral therapies, medication and recommended aftercare modalities — Recovery Support Services (RSS) — intended as a continuum of care and lifestyle supporting long-term recovery.  Even after a year or two of remission is achieved through treatment and a positive mutual support system, it can take three to five more years before the risk of relapse drops below 15 percent, the level of risk that people in the general population have of developing a substance use disorder (SUD) in their lifetime. [2]

[1] “Psychotherapies, What Is Psychotherapy?” NIH: National Institute of Mental Health, February, 2024.  https://www.nimh.nih.gov/health/topics/psychotherapies

[2] “Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health,” Office of the Surgeon General, November 2016, 5–7. https://store.samhsa.gov/product/Facing-Addiction-in-America-The-Surgeon-General-s-Report-on-Alcohol-Drugs-and-Health-Full-Report/SMA16-4991

There are two types of assessments through which the individual goes: first over-the-phone with a rehab’s admissions tech and the other during the intake process upon arrival at the facility.

The assessment over the phone is necessary so that the rehab can confirm they are or are not an appropriate match with the candidate. During that assessment, it is crucial that the individual be completely honest and truthful about his drug use — I mean everything. To help ensure that honesty, it is imperative that no one overhears his side of the conversation. The presence of a parent or family member often constrains the candidate’s truthfulness. 

Total honesty about substance use and/or mental behavior is vital in the facility’s judgment to accept the individual or not. That is especially true if the treatment is insurance-dependent since the insurance company’s authorization of the several levels of treatment necessary is dependent on the individual’s actual drug use  —  not sugar-coated to make it seem less than it really is.

Assuming the facility and candidate are a good fit, a more detailed clinical assessment by a licensed drug and alcohol counselor, psychiatrist, or psychologist, plus a physical exam by a physician, occurs upon arrival at the facility. This intake process includes a screening for substances, a detailed history of abusing them, a mental health evaluation, and a contraband / prohibited items check of the individual’s personal items. Plan on this process taking several hours.

Complete detailed history of substance misuse and mental disorders.

• Age, gender, and ethnicity

• Substance(s) of choice, length of use, date and amount last used

• Current health issues or needs

• Medical history

• Family history of substance use and mental disorders

• Suicide attempts or ideation

• Current medications

• Effects of substances on the person’s life

• Cultural issues around the use of alcohol or drugs

• Familial relationships

• Social relationships, issues, and needs

• Legal or financial problems

• Current living situation

• Employment history, stability, problems, and needs

• If relevant, school performance, problems, and needs

• Any previous treatment experiences or attempts to stop substance use

• What he/she wants for his/her life

Over-the-phone is initial assessment between individual and rehab to determine appropriateness of rehab’s program; Intake is the in person physical and mental assessment upon individual’s arrival at rehab.

Detox (detoxification) is medically supervised withdrawal and stabilization in an inpatient hospital or hospital-type setting with twenty-four-hour hospital‐type care. At best stabilization, the purpose is to make a patient medically stable and as free as possible of substances prior to the start of long-term treatment, typically thirty days of residential treatment as the next stage. Many facilities place the client in detox for the first twenty-four hours for observation as a matter of course anyway. Units set up specifically for detox are located in hospitals, rehab facilities, or third-party independent units.

Detox consists of three components:

• Evaluation of the substances ingested require medically assisted withdrawal. If needed, it could last three to ten days, depending upon the substance(s) involved. 

• Stabilization. Alcohol, opioid, and tranquilizer abuse produces significant physical withdrawal side effects that can lead to seizures and other health consequences. Their misuse requires withdrawal management for sometimes up to ten days.  Stabilizing psychosis (increasingly from marijuana use) can take up to several weeks in a hospital’s psych unit.

• Preparation for long-term care, such as residential treatment, which is the next step of a one-year treatment plan.

If Resources Allow

Research studies confirm and treatment experts insist that anything less than 90-days of formal treatment beginning with residential treatment, including medications and behavioral therapies, is of limited effectiveness.  However, not everyone has the resources for that, so we make adjustments to fit those resources.

Residential Treatment (RTC)

For those who are just out of Detox, who are prone to relapse or have a co-occurring illness, Residential Treatment Center (RTC) provides the intensive, twenty-four-hour care and support needed at that time.  

The real meat and potatoes of treatment, residential care focuses on modifying behavior regarding substance use, resocializing individuals through personal accountability and responsibility, and helping people build socially productive lives. The program’s highly structured treatment can be confrontational with activities designed to help residents examine damaging beliefs, self-concepts, and destructive patterns of behavior and adopt new, more harmonious, and constructive ways to interact with others.

Day 1-thru-30

RTC typically takes place in a hospital-like setting for a twenty-four-hour, thirty-day highly structured and supervised program using evidence‐based therapies, medication, and clinical and holistic services. The facility also provides living quarters for the patients, hence “residential.” Its setting can be rural or urban, on a campus in a dormitory-like setting, in cottages, or in a residential home where all associated activities take place.

MAT — Medication-Assisted Therapy; Meetings — support group meetings, 12-step, SMART Recovery, Al-Anon, etc.

Partial Hospitalization Programming (PHP)

Day 31-thru-60

Partial Hospitalization Programming (PHP) is residential treatment delivered on an outpatient basis. Frequently, it is referred to as “residential lite.” Typically, PHP involves one of the following:

• Treatment continues as it has during the residential stage.

• Treatment continues at the same setting, but the patient is moved to off-campus housing, also called sober living.

• Treatment occurs at an off-campus clinic owned and operated by the facility or by an outside provider, and the patient moves to off-campus housing.

Typically as the first stage of outpatient treatment, PHP is a milestone because the patient is leaving the cocoon of RTC to live in a separate sober living environment with others who are also transitioning back into “real life.”

Outpatient treatment (PHP, IOP, OP)

PHP serves three purposes: continuing care for those recently discharged from a residential program, less intensive group-therapy programs at the initial level of care for those with mild to moderate SUDs or simply don’t have the resources for RTC.  Requiring fewer resources than the conventional 90-days of formal treatment, Outpatient care is the most frequent type of behavioral health treatment provided at an average of 84% of substance use disorder and mental health programs (17,372 of them) in the U.S.

Intensive Outpatient Programing (IOP)

Day 61-thru-90

Intensive Outpatient Programming (IOP) is the second stage of outpatient treatment. As a less intensive schedule of therapy, it allows the individual to integrate further into the “real world.” Continuing to reside in sober living, the individual has a choice of morning or evening sessions at a clinic or occasionally on-site to make time for getting a job, continuing education, or performing community service. At this stage of the treatment plan, the individual’s social network of those living in sobriety is growing. New relationships and support are now becoming integral parts of the patient’s life.

Sober Living - a substance-free home environment and mutual support among fellow residents.

While most attention is on the formal treatment process or action stage — RTC, PHP, IOP — not enough attention and respect is given to what I think is the most difficult part of the treatment process — aftercare, the maintenance stage after formal treatment.  

A constant feature of an individual’s action stage is the hourly & daily plan providing structure necessary to apply the tools learned through evidence-based therapy and the mutual support of his peers to manage his disease. It’s not about willpower.  Willpower always breaks down. 

The last thing treatment professionals want is for the individual to wake up that first morning upon returning home after formal treatment and starting a new life is to ask himself, “okay, what do I do now?”  

A well planned and executed aftercare program is about providing structure.

Relapse

60% of those who went to rehab, relapse within one year of discharge.

The goal is to live a recovery lifestyle, which normally takes years to acquire, depending on any relapses along the way.  If there is relapse, this indicates a need to change some components of treatment plan, not that treatment has been a failure. Relapse is frequently part of the journey to recovery.  The best way to prevent relapse is structuring the right plan for the individual, knowing that it will need adjustments along the way.

Source: National Institute on Drug Abuse (2020). Art: ©The Right Rehab, LLC.

Sober Living

Sober living provides both a substance-free environment and mutual support among fellow residents. Statistics show that those who stay in sober living for at least one year have a much higher rate of maintaining sobriety than those who don’t, and the rate is still higher if the stay is three years. Additionally, one trial found that those with severe SUDs who lived in sober living after treatment “were 2 times more likely to be abstinent and had higher monthly incomes and lower incarceration rates” [3] two years later versus those who did not reside in sober living.

[3] Office of the Surgeon General, “Facing Addiction in America,” 5–11.

• Drug testing: Random drug tests are universal, although consequences for a positive test vary. 

• Contraband search: Searches of individual rooms and the whole premises occur on a random basis. Different places have different penalties.

• If you don’t have a job, you have two weeks to get one. If you are going to IOP, OP, or individual counseling, arrange your schedule to accommodate all activities. If you’re not employed, you must be in job training, continuing your education, or performing community service.

• Meetings: most houses mandate attendance at a set number of meetings per week, whether these are AA, NA, SMART Recovery, or Celebrate Recovery. If the individual does not have a sponsor, it’s time to get one.

Recovery Support Services (RSS)

RSS is a continuum of care and lifestyle intended to support long-term recovery. How long does that take? “A lifetime” is what my friends in recovery tell me. The RSS must include sober living, mutual-aid support (meetings), new positive relationships, and work or continuing education in an environment supportive of a recovery lifestyle that becomes a road map for a lifetime of continued recovery. That lifestyle should include individual and group outpatient sessions, plus if necessary, continuing medication-assisted therapy (MAT) but with a plan to eventually taper off its use.

Recovery support is exactly that — a foundation in maintaining sobriety, preventing relapse, and living a lifestyle of recovery for a lifetime. There are several sources supporting for that, including the following:

• Outpatient programming (OP) that steps down group to one hour per week of organized group therapy

• Private sessions with a psychologist or licensed counselor if possible

• Continued living in a sober living environment

• Peer support, including continuous attendance at 12-step or other type of support group. 

• Job search or job training

• Continued education

• Healthy nutrition 

• Transportation availability

• Legal assistance

• Community service

• Fitness

• Childcare, if necessary for employment

MAT (Medication-Assisted Therapy)

Controversial in some circles, a lifesaver in others, MAT is a “combination of behavioral interventions and medications to treat substance use disorders that studies have repeatedly demonstrated its efficacy at reducing illicit drug use and overdose deaths.” [4] These are not magic pills that “cure” addiction, but medications combined with evidence-based therapies have proven to produce higher rates of remission, shrink the gap between treatment need and availability, incur lower costs of treatment than without it, and reduce the rates of relapse, cravings, and especially the risk of death due to overdose.

[4] Office of the Surgeon General, “Facing Addiction in America,” 4–21.

MAT combines behavioral therapies and FDA-approved medications, including methadone, buprenorphine, naltrexone, and vivitrol, to produce stable levels and eliminate uncontrollable cravings. 

Scientific evidence suggests that relapse rates are high when tapering off these medications and treatment programs too early. To be effective, maintenance treatment should not be fewer than ninety days, and one study suggests that individuals who receive MAT for fewer than three years are more likely to relapse than those who benefit from its treatment for three or more years. [5] Ultimately, the individual could continue using MAT and slowly taper off it at a time of his choosing or continue its use for the rest of his lifetime.

[5] Office of the Surgeon General, “Facing Addiction in America,” 4–21.

Mutual Support Groups

Not to be mistaken as a substitute for treatment, 12-step self-help groups such as AA (Alcoholics Anonymous) are integral to a person’s aftercare in maintaining sobriety and living a life in recovery. Its mutual support is based on members sharing a problem, and through experiential knowledge and peer support, they learn from each other and focus on personal-change goals. AA is built on two guiding principles — a 12-step plan of action and the existence of a higher power than oneself — and studies show that 50 percent of those who started attending AA meetings after formal treatment are still participating in meetings three years later. [6]

[6]  Office of the Surgeon General, “Facing Addiction in America,” 5–9.

Although AA is the most well-known of mutual-support or self-help programs, it certainly is not the only one; others include Narcotics Anonymous (NA), Al-Anon, Cocaine Anonymous (CA), SMART Recovery, and Celebrate Recovery.

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