For psychotherapists who specialize in addiction, the ultimate goal is to move clients from clinical care to self-care, a process that means “working on my recovery” eventually becomes “working on enjoying my life.” This is true regardless of the addiction, be it substance abuse, compulsive gambling, spending addiction, video game addiction, or sex, porn, and love addiction. The hope is that over time an addict will blossom into a more intimately connected, happier, and more confident individual who no longer feels an automatic need to self-soothe with an addiction in the face of life’s challenges.
Unfortunately, this transition does not occur overnight. It takes time and a great deal of effort, and the treatment arc passes through several basic stages along the way.
First Clinical Contact
Most addicts who enter (often previously avoided) formalized treatment do so in moments of extreme crisis, with that crisis being a direct consequence of their addiction. After many months (or years) of stumbling blindly through the haze of addiction—sometimes doing a great job of covering their problems, other times just barely scraping by—their addictive behavior escalates to the point where it completely takes over and their functional world devolves into a chaotic muddle of ruined relationships, job loss, legal issues, financial woes, physical ailments, depression, anxiety, and social/emotional isolation. Usually, it is only when life consequences pile up and overwhelm that addicts seek outside assistance. So getting fired, or a threat of divorce, or felony charges, or some other dire circumstance is often the primary motivator for treatment.
It would be nice (and a lot easier, from a treatment perspective) if addicts showed up and said things like, “I’m unhappy and I want to live differently, and I’m pretty sure that starts with getting sober.” But typically, at least in clinical settings, that does not occur. More often, addiction treatment specialists hear things like, “My wife says she’s going to leave me if I don’t sober up,” or, “My attorney says it will look good to the judge if I’m in treatment.” Regardless, the addict is in treatment, which is a good thing.
The Initial Focus
Regardless of an addicted client’s initial motivation to seek help, early clinical efforts typically focus on three things: stopping the problematic behavior; assessment; and crisis management.
With substance abuse issues, stopping addictive behaviors may involve physical detox. At times, medical assessments may indicate a need for biochemical intervention. For instance, opiate abusers may detox with titrated doses of buprenorphine (Suboxone), while alcohol abusers may detox with steadily decreasing doses of chlordiazepoxide (Librium). These and similar drugs help to alleviate many of the more unpleasant (and dangerous) manifestations of chemical detox, including delirium tremens, nausea and/or diarrhea, chills, sweats, fevers, hallucinations, nightmares, and the like. Medical intervention of this type also serves a secondary purpose: keeping addicts in treatment. If faced with these the unpleasant symptoms of detoxing head on, many people will simply walk out of treatment and start using again. Proper use of medications can prevent that.
Once an addict is stabilized and no longer using, a complete psychosocial and physical assessment should be conducted, with clinicians looking for any and all addictive behaviors, underlying psychological issues (especially unresolved early-life trauma issues), secondary psychological issues (especially depression and anxiety), and medical issues both related and unrelated to the addiction. Based on this full assessment of the client’s needs, both short-term and longer-term plans of action can be developed, agreed upon, and embarked upon.
At the same time, clinicians must be aware of the addict’s life crises, helping the client understand and manage these issues without losing focus on sobriety, psychological recovery, and physical healing. At times, addicts are far more interested in fixing the issues that seem most pressing to them—their presenting crises. If they are insistent with this, it can derail other aspects of treatment. In such cases, clinicians must educate clients about the fact that until they establish sobriety and a modicum of psychological health, their life problems—the consequences of their addiction—are unlikely to resolve or stay resolved in any meaningful way. In other words, first things first, and the first thing is sobriety.
Generally, the crisis stage of treatment (especially if medical detox is needed) best takes place in an inpatient care facility, where the addict is physically and emotionally separated from the people, places, and things that drive his or her addiction. If the addict’s underlying issues and environmental triggers are not too severe, this work can also be done in an outpatient setting, especially if it’s an intensive program (all day, every day, for at least a few weeks).
Early Clinical Goals
A primary goal of early treatment is for addicts learn about their addiction—what it is, what it’s costing them, what drives it, and how to overcome it. To this end, addicts are given regular assignments and their work is typically shared and discussed in group settings, where they receive useful feedback from both therapists and their recovering peers.
Another primary focus in early treatment is breaking down the addict’s denial—the intricate web of lies the addict has woven as a way to justify his or her addiction. Beyond that, the addict is encouraged to develop healthy coping mechanisms that he or she can turn to when triggered toward relapse.
Additionally, underlying issues that drive the addiction (early-life trauma, for instance), are uncovered and examined in a general way, so the addict understands their role. However, deep trauma work, which by its very nature can trigger a desire for emotional escape and therefore a desire for relapse, is postponed until the addict has solidly established his or her sobriety—typically for six months or a year, or maybe longer if the addict seems vulnerable to relapse.
After an inpatient or intensive outpatient rehab, outpatient relapse prevention therapy moves to the fore—individual and/or group—with non-therapeutic addiction focused social support groups also playing an increased role. These include church sponsored groups, smart recovery groups, and, most often, 12 step recovery groups. Whatever the setting, addicts are surrounded by others struggling with the same or similar issues, so the work of overcoming denial, being accountable, and coping with addiction triggers in healthy ways continues unabated.
In the longer-term therapeutic milieu, work is usually focused on the development and implementation of life skills. If the addict’s inciting crisis or crises are still in play, this too will be addressed. (Once again, early-life trauma issues are best placed on the back burner until the addict has established solid sobriety.) Generally, recovering addicts are coached to be reliable and accountable in all aspects of life, especially with loved ones and their employers. Additionally, healthy coping skills are further developed and practiced—calling supportive others in recovery, developing a spiritual life, being social without engaging in an addiction, etc. Basic self-care is also in play, with addicts learning about exercise, eating right, proper sleep, hygiene, managing finances, etc. At times, learning to effectively communicate is important, as many addicts either never learned or fell out of practice with this while active in their addiction.
Eventually, after sobriety is solidly established, clinical work focuses less on in-the-moment life management and more on underlying issues—in particular the resolution of early-life trauma. As with the addiction itself, this work can occur in either inpatient or outpatient settings. Generally, outpatient therapy is fine, but those with serious and deeply rooted trauma might once again require the safety of an inpatient setting.
As for the addiction, non-therapeutic support takes over. Typically, recovering addicts attend at least one and usually several 12 step meetings per week. Some go to meetings daily. These individuals reason, “I drank/used daily, so I need to do something for my recovery daily.” And it is hard to argue with that logic, because those who go to meetings regularly are the ones who are most likely to maintain long-term sobriety.
In a general way, recovering addicts grow more self-sufficient over time. They learn to trust, to be vulnerable, to be humble, to communicate, and to be of service to those who are still struggling with active addiction and/or early sobriety. They become accountable, financially self-supporting, and social in healthy ways. They are honest, they care about others, and, most importantly, they are able to cope with life on life’s terms. If and when things go awry, as inevitably occurs in any person’s life, these individuals automatically turn to the tools of recovery instead of their addiction.
When addicts reach this stage of their recovery, they generally say thank you and goodbye to their therapist, relying instead on 12 step and other social support groups for ongoing assistance. Moreover, they use their personal experience, strength, and hope to guide other addicts who are looking to establish and maintain healthy sobriety. In a way, the students become the teachers.
As a long-time addiction treatment specialist, that is the moment I live for. Certainly the client is not “cured” when he or she decides to move on from clinical care. He or she will always be a recovering addict, in need of some form of outside assistance and feedback, but that assistance and feedback can easily be found in 12 step and other socially supportive settings. Thus, the client can live a healthy and happy life without my input, and my work is successfully completed.