detox and then refuse to attend treatment.
Medical detoxification is only the first step. A lot of addicted people come in, especially to a medical facility, and say, “I’m here to get detoxed,” or “I want to get detoxed.” Once they’ve been detoxed I say, “I now want to set you up to go see a counselor or therapist to go over addiction treatment.” Their response will sometimes be, “No, I’m not interested in that; I only came to be detoxed.” Addicts come in all stripes. We have patients at our clinic who come in for detox and we never see them again. And there are those who come back six months or a year later for detox again. They won’t meet with a counselor, won’t get any kind of treatment, and don’t establish any real abstinence, nevermind recovery. And we don’t see them again until the next time they need detox.
I always tell people that even when addicts can stop using, the problem is they don’t stay stopped. They stop for a day or two, or a week; they stop for two weeks, or even a month. And then they go right back to using again.
What defines success in addiction treatment? For people who complete a treatment program, one basic definition of successful treatment is no substance use and no criminality for a minimum of two years. Positive outcomes are correlated with adequate lengths of treatment. Success depends in part on whether patients remain in treatment long enough to experience and integrate its full benefits. As a generalization, the longer people remain in treatment, the better their chances of remaining abstinent and achieving recovery. And whether a person stays in treatment depends on multiple factors related to both the individual and the program.
Important individual factors include personal motivation to change, family dynamics, social supports, medical insurance, and other financial resources, as well as outside pressure to stay in treatment. Such factors include the criminal justice system and the Child Protective Services system, where the options are often either addiction treatment or incarceration, or potential loss of the custody of one’s children. Other external motivating factors are the person’s partner/spouse/family and his or her employer. All of these variables can play a role in whether the person enters and remains in treatment long enough to complete it or not.
These individual variables assume many different configurations, consistent with the diversity of addiction treatment patients. This diversity ranges from (for example) the previously high-functioning Beverly Hills attorney who is abusing alcohol to the schizophrenic high school dropout who is shooting heroin and living under the freeway overpass.
The Beverly Hills attorney is the head of his law firm, is married and has two kids, went to Harvard, and makes a million dollars a year in his law practice. One day, he comes home and an intervention is waiting for him. His wife, his law partner, and his kids are all sitting there with a trained interventionist, and they all say in various ways, “Listen, we love you, but we don’t love your drinking.” You know how the rest of it goes: “If you keep drinking we’re going to leave, we’re going to turn you over to the state bar, you’re going to lose your law license, we’re going to remove you from the law firm, and all these bad things are going to happen unless you go into a treatment program.”
Then there’s a heroin addict with an eighth-grade education who has schizophrenia, who contracted HIV from intravenous drug use, has no job skills, and is hearing voices. How do you compare these two situations? Obviously, there are many significant differences between these two people.
There are also treatment program factors related to retention. It is essential for counselors to establish positive therapeutic relationships with clients as early in treatment as possible, and ensure that a treatment plan is developed and followed in collaboration with each client. Clients also need information and psychoeducation regarding what to expect both structurally and experientially during treatment. Medical, psychiatric, and case management services should be available concurrent with psychosocial addiction treatment, and transitions to step-down continuing care or aftercare need to be agreed upon well in advance and be as seamless as circumstances allow.
Something that comes as a surprise to a lot of people is that individuals who enter treatment under legal pressure have outcomes that are just as successful as those who enter treatment voluntarily. That seems counterintuitive, doesn’t it? We tend to think that somebody “forced” into treatment because the court has given him or her the choice of treatment or jail would rebel against the process. Of course some people do rebel against the structure and process of addiction treatment—but that happens regardless of whether their motivation is primarily internal or external.
Interestingly, once many people who are mandated to enter treatment are exposed to recovery, positive things happen, and a lot of people begin to turn their lives around. I tell patients that “I don’t care all that much about the reason why you’re here. I don’t care if you’re here because your wife or your husband or your parents sent you, or if it’s the court or Child Protective Services that made you come, as long as you’re here. If you want to do it for your wife or whomever, do it for her, just as long as you’re here, and then we’ll see what happens after that.”
Here’s a critical point for aspiring addiction treatment professionals to consider: not everybody wants to stop using. That’s something you need to learn right now so your expectations can be set realistically, and you don’t burn out from the frustration and disappointment of not succeeding with all of them. Often, it’s much more than denial that we have to deal with. While many people don’t stop because they are in denial and contend that they “don’t have a problem,” there are people who simply don’t want to stop using alcohol and other drugs and are not yet ready to stop, despite the adverse consequences they have experienced to that point.
In order for addiction treatment to be effective, addicts usually have to get to the point where the pain of using and everything that goes along with it significantly outweighs the pleasure and/or relief that using brings. We used to talk about the need for people struggling with addiction to “hit bottom,” but at a minimum, addicts need to get to a place where they are confronted unavoidably with the reality that the negative consequences of using far exceed the perceived benefits. Ambivalence is common, even if technically, a person is not being “forced” into treatment.
A skilled counselor can tip the scales of this ambivalence by helping the patient to specifically identify the “good” things that he or she gets from using, as well as what using has cost, continues to cost, and is likely to cost him or her in the future. As this list is formulated and processed, it usually becomes clear that the costs of using are greater than its benefits, that the advantages can no longer compete with the disadvantages. This helps people come to the realization that they really don’t wish to continue living the way they have been, and they become willing to enter treatment.
Over the last decade or so, drug courts have evolved as an innovation wherein both drug abuse/addiction and criminal acts can be addressed in an integrated way. The most effective models incorporate criminal justice considerations with drug treatment that includes screening, placement, counseling, testing, monitoring, and supervision, and often include attendance at twelve-step meetings. Treatment should also include assessment and counseling for high-risk infections such as hepatitis C and HIV. Intravenous drug users, in particular, are going to be at considerable risk for these viruses. I’ve rarely met an IV addict who didn’t have hepatitis C. Many of the patients you will work with in addiction treatment are going to have HIV, they’re going to have hepatitis C, they’re going to be pregnant (with complications), and they’re going to have a range of medical problems from their using. We’ll cover these commonly seen medical comorbidities later.
Sometimes it isn’t possible to motivate clients externally to seek treatment. I recall one patient many years ago who had AIDS and was addicted to crystal meth. The only reason he periodically came to the hospital was because he was running out of money and running out of drugs. He had abscesses all over his body from injecting drugs and by the time I saw him, he had
