An overview of the treatment process can serve as a roadmap to help navigate the entire recovery process.
The National Institute on Drug Abuse (NIDA) provides extensive guidance on what to expect from addiction treatment. Although there are more than 14,500 drug treatment centers in the US, most follow similar methodologies.
Painting the picture of addiction treatment with the broadest strokes, the two main features of rehab today involve medications and behavioral therapies. Within these main categories, there is a host of treatment approaches. As addiction is a complex disease, its treatment requires a multifaceted approach to address its many aspects. Further, to properly execute treatment, a multidisciplinary staff is helpful, including:
- Drug counselors
- Social workers
- Competent support staff
- Ancillary staff
In general, addiction treatment occurs in four settings: drug treatment centers, physicians’ offices, mental health clinics, and hospitals. Programs are either residential or outpatient. As the names suggest, residential program participants live on site at the treatment center whereas outpatient clients join a day or evening program and live off site the rest of the time. There are no hard-and-fast rules as to whether a person seeking recovery should join an outpatient or residential program; the decision is a matter of life circumstances and an addiction specialist’s recommendations based on the individual client. Treatment depends on the type of substance abused and the patient’s particular drug history and risk factors.
Moving Through Treatment
Addiction treatment is a highly structured enterprise. For this reason, rehab clients should expect a similar type of treatment progression from their recovery services provider. As NIDA lays out, the following are some steps to expect:
- Step 1 – Intake: At the time of admission, an incoming client will be asked to provide her full drug history and treatment goals.
- Step 2 – Treatment Plan: This usually commences with detox and is based on the intake information and any medical evaluation. Addiction specialists will work in a team to devise an individualized treatment plan.
- Step 3 – Drug Counseling and Psychotherapy and Behavioral Therapy: This is one of the main pillars of treatment, and it occurs on an individual and group basis.
- Step 4 – Pharmacology: When available, medication-assisted therapy (MAT) can help individuals recovering from opiate, alcohol, benzodiazepine, barbiturate, and nicotine dependence.
- Step 5 – Support Groups: During professional treatment (and after graduation), those in recovery are encouraged to attend peer group meetings, such as Narcotics Anonymous.
- Step 6 – Ancillary Services: As an added measure to prevent relapse and promote a healthy life, recovering individuals may be provided with services that help with child care, employment, education, HIV/AIDS, housing, transportation, and legal advice.
- Step 6 – Aftercare: This is a critical component of addiction treatment. Recovering individuals may continue with an outpatient program, live in a sober living facility, regularly meet with a drug counselor and psychotherapist, and attend recovery group meetings.
There are many stakeholders in the recovery process, including the substance abuser himself, his loved ones, treating professionals, and society overall. A main factor in the goal of long-term abstinence is the amount of time a person spends in a professional treatment program and his level of commitment. Prevailing treatment wisdom advises that a minimum of 90 days in a professional rehab program is required, and in the case of methadone therapy recipients, at least 12 continuous months. The treatment process should be tightly woven, with each core treatment approach working to keep a client in rehab and help him not only to recover but also to develop new drug-free living strategies.
As NIDA discusses on the topic of detox, this process occurs when a person ceases or significantly reduces drug intake, resulting in the manifestation of withdrawal symptoms. Addiction specialists agree that detox alone is not sufficient to end addiction in the long term. Detox is a critical first step in the rehab process, but it does not address the psychological, social, and behavioral dimensions of addiction.
During a medically supervised detox, medical staff can safely taper a person off drugs, and more comfortably manage the withdrawal process. Although much of the discomfort associated with withdrawal can be safely treated with over-the-counter pain relievers, withdrawal from drugs such as alcohol, opiates, and benzodiazepines can be dangerous. It is never possible in any given detox case to perfectly assess the intensity of the withdrawal process. For this reason, a medically supervised detox (versus quitting cold turkey on one’s own) overseen by consulting physicians is the best practice, especially when the drugs of abuse include alcohol, opiates, or benzodiazepines.
Doctors and other medical staff members who provide a supervised medical detox will follow established treatment protocols and only use FDA-approved prescriptions. In general, detox can last three to 14 days. A consulting doctor or other qualified professional can advise as to where the treatment should occur, such as in a hospital or residential or outpatient facility. After detox, the recovering person should immediately commence treatment at a specialized drug rehab center.
After detox, a recovering person enters the abstinence maintenance treatment phase. There are three main possible components of treatment: medication-assisted therapy (MAT), drug counseling, and psychotherapy. As previously mentioned, only those who are recovering from dependence on opioids, benzodiazepines, barbiturates, alcohol, and nicotine are candidates for MAT. Compare this program, for example, to the treatment of cocaine abuse disorder; at present there are no FDA-approved medications for cocaine abuse, although such a methodology would be welcomed in the field). Although MAT is limited in its scope, all in recovery could benefit from drug counseling and behavioral therapy. The White House discusses the types of MAT available for those recovering from opioid abuse disorder. At present, there are three medications approved in this area: methadone, buprenorphine (with or without the addition of naloxone), and naltrexone. Many people around addiction or suffering from it have likely heard of Subutex and Suboxone, as they are two types of branded MAT drugs.
Subutex is composed of buprenorphine alone whereas Suboxone includes both buprenorphine and naloxone. The drug naloxone serves as a guard against abuse via injection of buprenorphine; when a person injects buprenorphine, the naloxone blocks the buprenorphine and causes withdrawal effects to set in. As this is an undesirable experience, there is a disincentive to abuse Suboxone via injection. Subutex is generally used in the earliest phase of opioid dependence treatment, but some recovering persons who cannot tolerate Suboxone will remain on this drug longer term.
It is important to note that not all drug treatment centers are equipped to provide MAT. During the intake or detox process, an appropriate referral should be made for those recovering from the drugs of abuse, such as opioids, for which MAT is advisable.
Drug counseling is a vital part of the abstinence maintenance process. The focus is mainly on stopping, reducing, or preventing drug abuse. This rehab program feature can best be thought of as proving short-term pragmatic help; drug counseling, clients are educated about the nature and consequences of drug abuse, taught coping strategies to handle drug cravings, and provided with tools to help them abstain.Drug counselors encourage clients to fully participate in their drug treatment program, and to join independent recovery groups such as Narcotics Anonymous or Alcoholics Anonymous. A drug counselor may also help a patient to navigate the public benefits system (as necessary) and get help with any housing, transportation, child care, or employment needs.
A cornerstone of care, psychotherapy occurs in both an individual and group format in treatment programs. At present, the most commonly used individual psychotherapy methods include Cognitive Behavioral Therapy (CBT), contingency management interventions, motivational enhancement therapy, and family behavior therapy. An attending psychotherapist may use one of a combination of treatment approaches. CBT is among the most popular.
As PsychCentral explains, CBT was developed outside of the drug addiction treatment context but has been successfully adapted to this area. Its approach is a blend of psychotherapy and behavioral therapy; psychotherapy focuses on people’s thought patterns beginning in childhood while behavioral therapy looks at people’s thoughts, behaviors, and problems.
The main goal of CBT is to identify and change a person’s unhealthy thought and behavioral patterns to bring about personal transformation. This treatment occurs in one or more 50-minute sessions per week and helps a person to investigate her thoughts so as to not act impulsively or mindlessly. Bringing greater mindfulness to one’s actions can have a positive downstream effect of ameliorating one’s life overall. The following are some additional benefits a recovering person can expect to receive from CBT:
- A structured session opening with the patient stating problems and goals rather than talking freely
- Practical strategies to cope with drug triggers and life stresses
- Thoughts can create a negative downward spiral, and CBT techniques can help to intercept and heal them
- An equality-based relationship with the therapist, who is more akin to a colleague helping to tackle a problem and come up with a good solution and implementation plan
One of the greatest benefits of CBT is that research shows it has lasting effects. During CBT sessions, a person is essentially deconstructing old patterns of thinking, such as drug dependence, and building the infrastructure for a new way of thinking, such as being drug-free and pursuing personal goals. A new mental framework, and ensuing positive life experiences, provide a strong bulwark against relapse. At the outset of treatment, a rehab client may inquire with her counselor about treatment philosophies. Most psychotherapists are responsive to patients’ needs and will adapt the process to optimize both treatment efficacy and comfort. The best practice is to be open and honest with the attending therapist about how the sessions are working out.
The Substance Abuse and Mental Health Services Administration (SAMHSA) provides an in-depth look at group counseling in general and in the addiction treatment context in specific. SAMHSA highlights that group therapy is different from 12-Step self-recovery groups. A therapist leading a group session should have experience in this setting, as dynamics and the healing progression are different than those seen in individual sessions.
SAMHSA conceives of group therapy in three stages of treatment: early, middle and late. In the early stages of treatment, group members may be ambivalent about abstinence, have cognitive impairments due to the drug abuse, and feel emotional turmoil at the transition from using drugs to being sober. The therapist leading the group will have to respond to the resistance met and employ motivational tactics that can be increasingly retired as the treatment process progresses. From a group member standpoint, being vulnerable at this stage of treatment can pave the way for bonding with the therapist and group. In other words, the fragility of this stage can work to pave a strong foundation for the group’s healing process.
During the middle stage of treatment, group members tend to have better cognitive functioning. As a person’s mental state improves, having been sober and away from addicted living for some time, positive peer group reinforcement can help to achieve stability among individual members and the group as a whole. At this point, a therapist’s main strategy will likely be to help members of the group to mobilize toward change. Whether the motivation stems from wanting to reunite with family and/or go back to school or work, a therapist will at this point be sufficiently aware of the personalities and histories of group members to strategically encourage them to pursue their personal goals.
As group members undergo the late stage of group therapy, the abuse itself may recede to the backdrop as underlying issues, such as poor self-image, emerge. Such issues may have been underlying and motivating the drug use all along, but they can now be addressed because of the relief and clarity that sobriety brings. Relapse may occur, but addiction specialists are in agreement that the relapsed substance abuser is not the same as the original substance abuser. The lessons learned in rehab do not fade, and even though the strategies learned may not have been sufficient to avoid a relapse, they can help to pull a person back to sobriety again.
For many recovering substance abusers and addiction specialists alike, 12-Step meetings are a vital ongoing part of recovery. Although professional treatment in a clinical residential or outpatient is often somewhat limited in time, one can attend 12-Step meetings for their entire life – and many do. Twelve-Step meetings are so integral to the recovery process that many rehab programs will require patients to attend them while in treatment, in addition to group therapy.
As 12-Step meetings are self-directed (i.e., a trained counselor does not lead them), they are not run by a rehab program necessarily. A rehab center may host 12-Step meetings or require that clients attend them off site. Residential rehab centers may incorporate 12-Step meetings into the program and provide transportation to off-site meetings. Outpatient program participants may seek local groups, and speak with their counselor or social worker to address their transportation needs, as necessary. A high-quality outpatient rehab should work with clients to ensure that there are no barriers to treatment.
Twelve-Step meetings do not require commitment to only one group. A person is free to join any group, anytime, anywhere. There is no requirement to share present or past challenges, but all attendees are invited to speak. An added benefit is some members may find a sober sponsor – a person with a recovery history who volunteers his or her time, for free, to work individually with a recovering person.
To illustrate the importance of 12-Step meetings in the addiction treatment rubric, addiction specialist Patrick McGinnis notes that some addiction specialists recommend that newly recovering persons attend 90 recovery group meetings in 90 days. Of course, such attendance should not pursued in an addiction-like fashion, which is one criticism lodged against a rigid commitment to attending meetings. The greater goal in recovery is to begin to lead a more balanced life, with a desire for healthy living at the focus. Attendance at 12-Step meetings can be necessary, but a life commitment to sobriety is paramount.
After intensive rehab services, whether outpatient or residential, a recovering addict can begin the aftercare or ongoing care phase of treatment. Numerous treatment centers offer aftercare programs (residential or outpatient) as part of the tailored treatment program for the patient. In this way, the aftercare program serves as an extension of the initial drug treatment program.
As Everything Addiction explains, recovery does not end when professional treatment stops. For those recovering people who do not join a residential or aftercare program, a treatment professional can help a graduating rehab client to design a patchwork of local services aimed at supporting recovery. In addition to 12-Step meetings, some of the most common forms of aftercare include:
- Residence in a sober living facility
- Ongoing drug counseling
- Group therapy
- Drug education classes
- Recreation and social activities, including rehab alumni get-togethers
Aftercare programs generally last six months to a year, but there is no bar against continuing in any of these programs, especially 12-Step meetings (which can serve as a form of lifetime aftercare). Although it may not be considered formally be considered a form of aftercare, some with long-term sobriety get involved with helping newly recovering substance abusers – for example, a Narcotics Anonymous sponsor mentoring a new member. The founders of Alcoholics Anonymous (Bill W. and Bob Smith), who were former alcoholics, preached about how they felt they needed to convert other alcoholics to sobriety to help maintain their own sobriety. This sentiment is a testament to one of the greatest successes of drug treatment – the process can be so transformative that those who are healed feel compelled to help others.
Here at The Canyon, we provide our residential rehab clients with an expertly structured progression of services, beginning with detoxification and stabilization, moving to reflection and preparation, and ultimately to action. We understand the diverse needs of our clients and provide several additional program options, including residential treatment in Malibu, outpatient treatment in Santa Monica and Los Angeles, extended care, sober living, and an alumni program.
We are with our patients from the very first moment of admission through program graduation and beyond. Call us to learn more.