Addiction is a complicated, multifaceted issue, and the language that we use to talk about the entire spectrum of addiction can sometimes be overwhelming and intimidating. Each addiction story – from how it starts and the effects it has to how it is treated – is unique, and the words we use to talk about that process and experience have to be as clear and unambiguous as possible.
Some of the terms here will be standard to any addiction and treatment experience, and some will be specific to a particular form of addiction and a particular treatment approach. However, all of the terms here allow clinicians, doctors and health care providers to understand the many layers of addiction, and are related to how they help a patient or a family out of that darkness.
While the terms “addiction” and “(substance) abuse” are often used interchangeably, there are key differences between the two concepts. An addiction robs a user of the willpower to stop his behavior to the point that his life crumbles around him; those who only abuse drugs or alcohol (with no sense of addiction) still retain some measure of control over their lives. They are able to function at school or maintain their domestic responsibilities, even as they expose themselves to greater amounts of risk in the drugs and alcohol that they consume.
As a result of this, substance users can often change their behavior if they have enough incentive (getting a DUI, being given an ultimatum by a spouse, etc.). Addicts, on the other hand, cannot resist the temptation to drink or light up even in the face of threats and consequences.
If a person is physically or mentally dependent on a (potentially dangerous or harmful) substance (or behavior) to help them cope with difficult situations, to help them get through the day, or to alleviate the physical or mental symptoms of another problem, this would be termed an addiction. One of the important criteria for an addiction is if the person can quit the substance or behavior without experiencing direct negative ramifications as a result of no longer engaging in the behavior or consuming the substance. If they feel depressed, nervous, anxious, or tense, or if they have physical pain, feel nauseous, and have trouble sleeping because they are deprived of their consumption or behavior, then they are likely suffering from addiction.
Another critical component of an addiction is that the user will not be able to voluntarily stop the addictive behavior. For example, even if an alcoholic realizes that his or her drinking problem is causing difficulty at home, at school, or at work, he or she nonetheless feels an overpowering compulsion to seek solace in more drinking. Breaking an addiction is a very complicated, multi-step process that cannot be accomplished alone.
Adventure therapy is a form of treatment that encourages patients to become physically and mentally engaged in adventurous, outdoor activities, like hiking, camping, and endurance courses. The idea is that by boosting self-image and self-esteem, and by fostering an environment where participants are empowered to seek help from others, offer help to others, and act in ways that benefit the group at large, real change can take place.
Once a patient has completed detoxification and psychotherapy, the next step for them is to reintegrate into the real world, where the stressors and triggers that might have once caused addictive or harmful behavior are still present. Notwithstanding that psychotherapy would cover thought and behavioral control, confronting the challenges and temptations of daily life can make for a very stern test for anyone trying to maintain sobriety after treatment, to the point that relapse is most likely within the first three months of the patient returning to their normal life after treatment.
This is the focus of aftercare programs, like 12-Step groups and other forms of support systems. They provide a foundation upon which the patient can take her first steps away from professional, formalized treatment, but still remain connected to a body of people who understand what it’s like to do so, and who can provide encouragement and accountability to help maintain abstinence.
While attendance and participation in aftercare programs cannot be enforced, it is a universally good idea. The Journal of Substance Abuse Treatment reports that “adherence to aftercare therapy in substance abuse treatment is associated with improved outcomes.”
The Alcohol Research & Health journal identified key areas for a patient (and their family and friends) that should be part of a good aftercare support program:
- Many patients risk relapse because they continue to believe that the drugs or alcohol they used to take can still make them feel better about life. Members of aftercare support groups can offer constructive and firm reminders of examples of the harms of addictive behavior, as well as remind the patient of consequences if he relapses.
- Aftercare support provides the patient with a group of experienced, sympathetic people, who are always just a phone call away to help him work the program and call on the coping skills he learned in therapy.
- In a newly sober life, a stumble doesn’t have to be a fall. Lapses happen, and the quick help and support of an aftercare group can make the difference between an isolated slip-up and a full-on relapse.
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Cognitive Behavioral Therapy
The National Alliance on Mental Illness explains that Cognitive Behavioral Therapy examines the connections between the patient’s thoughts and feelings, and the actions they take based on their emotions. As a form of mental health treatment, CBT examines the patient’s patterns of thought that lead to harmful and self-destructive behavior, and helps the patient understand the cause-and-effect relationship therein. A trained therapist will then help the patient alter his thought processes, to help him cope with stressors and triggers in healthier and more productive ways than trying to self-medicate with drugs or alcohol.
As a form of evidence-based therapy, Cognitive Behavioral Therapy fits the bill: WebMD mentions one large-scale study of over 400 patients suffering “treatment-resistant depression,” where the application of CBT in conjunction with appropriate medication significantly reduced the symptoms of depression in the study’s participants.
Cognitive Processing Therapy
Another form of psychotherapy to help with trauma and addiction is cognitive processing therapy (CPT), which teaches patients new ways to handle their intrusive thoughts, and how to understand them in a way that can be accepted and controlled. CPT shows patients how going through their trauma changed the way they process the world, the people in their lives, and themselves.
A CPT therapist will work with a patient on how they can understand the nature of their symptoms, take stock of their thoughts and feelings, learn skills to cope with the residual mental effects of the trauma they experienced, and fully grasp how belief in the concepts of safety, trust, and self-esteem have changed as a result of the trauma.
Learning new and healthy ways of dealing with the trauma will be a significant factor in the treatment of a substance abuse addiction that has arisen from the event.
A co-occurring disorder is the presence of two (or more) simultaneous substance use or mental health conditions in the same patient (the terms “dual diagnosis” and “co-occurring disorder(s)” are sometimes used interchangeably).
The severity of each disorder may be disparate; that is, one disorder may be more severe than the other, or they may be of equal strength. This may change over time (the stronger condition and the weaker condition switch places), or cycle. Psychology Today explains that “there is no single combination” of co-occurring disorders, and that patients with a co-occurring disorder experience greater chronic medical, emotional and social problems.
Treatment has many distinct, but connected components, and one of them is detoxification.
According to the National Institute on Drug Abuse, drug detox is the process of inducing the patient’s body into a state where it can slowly free itself of the physical craving for drugs or alcohol, while simultaneously controlling the resulting symptoms of withdrawal.
Depending on the types of drugs or alcohol that the patient abused, the length of time they were abused, and a number of other factors, the length of the detox process can take anywhere from a few days to a matter of weeks.
Since detoxification is effectively controlled withdrawal, the patient will (likely) experience the symptoms typical of drug or alcohol withdrawal:
- Fluctuating blood pressure
- Muscle pain and cramping
- Cold sweats
- Uncontrollable tremors
To help a patient get through the withdrawal symptoms of the detoxification stage (which could literally be the difference between life and death), treatment staff members may administer carefully prescribed medications to ease the process.
Benzodiazepines (a class of tranquilizers that includes Valium and Xanax) have long been used as anti-anxiety medication to help alcohol addicts who are going through withdrawal. Benzodiazepines have a proven track record as drugs that satisfactorily guide the patient through the detox stage (accounting for 60 percent of inpatient treatment practices for alcohol removal).
An important component of detox is that it is not treatment in and of itself, which many addicts do not realize. They may feel that they have enough of a handle on their substance abuse that by simply terminating their intake, they will be able to successfully kick the habit and live a substance-free existence.
According to a blog on PsychCentral, detox is a complex medical process that entails far more than the simple cessation of drug consumption. An addict goes through a number of mental and physical changes as the result of detoxification, and these can be lethal if they are not carefully managed and supervised by a health care professional in the control and safety of a treatment facility. Alcohol Health & Research World found that five percent of patients who opt to go it alone experience seizures as part of the withdrawal effects of cutting off their alcohol use.
As a form of treatment, detox does not exist in a vacuum, and neither does addiction. Detox without the follow-up of psychotherapy will never address the risk factors and reasons that led a patient to substance abuse, and it may ultimately result in a relapse if the patient is not counseled on how to mentally free himself of his drug and alcohol cravings.
Dialectical Behavior Therapy
Dialectical Behavior Therapy (DBT) is the other type of evidence-based treatment in the psychotherapeutic spectrum of treating addiction disorders. DBT focuses on the social and environmental elements of the patient’s life, especially with regards to their friends, family, and romantic partners. The journal of Addiction Science & Clinical Practice considers Dialectical Behavior Therapy to be a “well-established” form of treatment that is particularly useful for treating patients who have multiple forms of psychosocial disorders, because “many such patients have substance use disorders.”
According to Addiction Science & Clinical Practice, there were nine published clinical trials (as of 2008) that evaluated Dialectical Behavior Therapy. The results supported the effectiveness of DBT in curtailing self-injurious behaviors, addiction, and depression, lending strong credibility to the use of DBT as a form of evidence-based treatment.
Many patients who have a mental health disorder also struggle with a substance abuse problem. This crossover is known as a dual diagnosis, and it is found either in the form of a person who has a mental health disorder and uses drugs or alcohol to alleviate their mental state, or a person who drinks or uses drugs to such a degree that their mental health is affected.
The mental disorders that are often found in a dual diagnosis situation are:
- Personality disorders
The key in treating a dual diagnosis condition is that both facets of it – the substance abuse and the mental health disorder – have to be resolved; merely focusing on one at the exclusion of the other will not help the patient, because the substance abuse and mental health disorder will be too deeply entwined to treat either in isolation. Patients with a dual diagnosis are also at an increased risk for relapsing into their substance abuse after treatment.
There are many treatment approaches offered to recovering addicts, but some of them are far more credible and established than others, especially given the sometimes disparate nature of the risk factors behind the addiction. Evidence-based treatment can be any form of psychotherapy that adheres to evidence that has been vetted by the scientific and healthcare community.
For a treatment method to be deemed “evidence-based,” it needs to have been studied in a number of large-scale (thousands of patients), long-term (lasting years at a time) clinical trials. The results of the treatment should be carefully compared to the effects of other types of treatment; a proper evidence-based treatment will be able to statistically show that it can effectively treat the psychological causes and symptoms of addiction (and/or an associated mental health disorder), as opposed to an alternative form of therapy that has no verifiable results to speak of.
Two of the most widely used forms of evidence-based treatment are Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT).
Family involvement is an important component in many forms of addiction therapy. It can be used as an educational tool, to enlighten members of the addict’s family on how their behavior was (unintentionally or otherwise) conducive to the development of a substance abuse problem. If there was the issue of familial enablement, a therapist can help the family understand how they can create a healthy and positive home situation for the addict. This may mean anything from curtailing drinking behavior when the patient is present, to developing empathy and communication to avoiding (or minimizing) issues of domestic tension and unhappiness that may contribute to an unhealthy home environment.
While the patient is at the center of treatment, family therapy also addresses the needs of the family unit. As a primary point of contact for the patient, siblings, children, and parents must sometimes bear the brunt of the addict’s behavior or the consequences thereof. As much as family therapy exists to show the family how they can help their loved one overcome the challenges of kicking a drug or alcohol habit, family therapy also exists for the addict to see how her substance abuse has harmed her loved ones.
The Substance Abuse and Mental Health Services Administration says family involvement in the treatment of any kind of health problem, including treatment of substance abuse and addiction, is key. To that effect, a study in the Archives of General Psychiatry of 101 bipolar patients found that those patients who had their families involved in their therapy relapsed fewer times, experienced less severe symptoms, and were more diligent in taking their medication.
Foundations Recovery Network
Foundations Recovery Network (FRN) is an organization of residential and outpatient treatment facilities that combines evidence-based treatment with an integrated model to provide patients with dual diagnosis disorders treatment options for their mental health disorder and substance abuse issues. FRN has centers across the country and sponsors events that encourage and reward sobriety, while serving as a beacon of inspiration to those who are currently struggling with an addiction.
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Heroes in Recovery
Heroes in Recovery is a program launched by Foundations Recovery Network to break the stigma that prevents many addicts from seeking help for their substance abuse. It does this by sharing stories of recovery to inspire patients who may be scared or embarrassed to ask for assistance, and by creating an active sober community that empowers recovering patients to get involved in sober events, tell their own stories, and lead (and live) by example.
Heroes in Recovery hosts 6K races across the country to spread the word of the importance of addiction treatment and to show support for those people who are currently in a treatment program.
See also: Foundations Recovery Network
While there is a standard body of work on the protocols for addiction treatment and therapy, alternative therapies have proven popular. In the same way that people might opt to see an acupuncturist or a hypnotist for an ailment or affliction, Eastern (holistic) medicine is also making its way into the substance abuse treatment paradigm. Practices like Reiki, energy psychology, and massage therapy may prove popular with people who have had bad experiences with psychotherapy or pharmacotherapy. Experts nonetheless warn that holistic therapy offers no significant advantage over standard approaches, and any holistic practitioner or center that claims their form of alternative medicine has been proven in arresting addiction and successfully rehabilitating a patient should be scrutinized.
Nonetheless, holistic therapies are not without their benefits. The mindset of offering treatment that addresses the mind, body, and even the soul (similar to the 12-Step philosophy) is one that might resonate deeply with people who have lost everything because of their substance abuse, and who believe that typical addiction treatment is too clinical.
Oftentimes, rehab services are categorized as either “inpatient” or “outpatient.” With inpatient rehab, patients reside at the treatment facility around the clock – they sleep, eat, and remain at the treatment center for the entire duration of their treatment.
The difference is important, as health insurance coverage depends greatly on the length of treatment.
Integrated Treatment Model
The integrated treatment model is the combination approach of treating a patient for her mental health condition and her co-occurring substance abuse disorder. The model focuses on the parallels between standard treatment models for issues of depression, anxiety, stress, panic disorders, etc., and the 12-Step approach for the treatment of addiction.
This method of therapy looks at both the substance abuse and the mental health issue as illnesses, each requiring specific treatment to address their respective symptoms, and set the patient on a process of recovery.
Intensive Outpatient Program (IOP)
An intensive outpatient program (IOP) is a form of concentrated care where the patient continues to live at home while undergoing treatment. Generally, an IOP does not involve detoxification to break the hold of illicit drugs or alcohol on a patient.
An IOP can be recommended after a clinical evaluation, if a doctor or other health care professional believes that a patient does not need detoxification. An IOP is a part-time, but strict, treatment routine that is meant to work the patient’s daily life into his recovery (as opposed to inpatient treatment, where patients have to put their regular lives on hold in order to focus on treatment).
Intensive outpatient programs have the luxury of defining short-term (often two-week) goals for the patient, but they also keep an eye on intermediate (90-day) and long-term (one-year) goals. Treatment sessions in IOPs lean more towards directly prepping the patient for re-engaging with society, contrasted with the therapeutic paradigm of traditional addiction psychotherapy.
As a result of this, patients enrolled in IOPs have the freedom to live on their own – residency at a treatment facility is not required. Patients are able to maintain jobs, go to school, and socialize with friends and family. However, they are responsible for attending weekly, or daily, sessions with therapists (at least nine hours a week, according to the American Society of Addiction Medicine), and implementing coping skills that they’ve learned in the process.
However, this is still an intensive outpatient program, so friends and family are required to be a part of the therapy at certain stages. Patients who have active engagement, support, and encouragement from their loved ones tend to move through therapy faster, and with better and longer-lasting results.
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Mental Health Disorder
A mental health disorder is an umbrella term for a number of conditions that can affect someone’s mental well-being. These conditions can include:
- Anxiety disorders
- Panic disorders
- Bipolar disorders
- Mood disorders
- Personality disorders
- Psychotic disorders
Mental health disorders may stem from genetic and family history, environmental triggers (like familial abuse or childhood trauma), biological factors (such as a head injury or a mother’s use of cigarettes, drugs, or alcohol while pregnant), trauma, or substance abuse.
Motivational Interviewing is a form of therapy that seeks to inspire and influence the patient to effect changes to his life from within himself. Instead of using coercion, persuasion, confrontation, and ultimatums, a therapist tries to help the client resolve the ambivalence in his life that keeps him from realizing his goals and instead seek solace in substance abuse.
In explaining Motivational Interviewing as a counseling style, the Substance Abuse and Mental Health Services Administration explains that there are two facets to it: the patient’s capability for exercising his free will and power of choice, and changing his life and behavior through a process of self-actualization.
See also: Cognitive Behavioral Therapy
Outpatient care, patients come to a treatment center at predetermined times but still live at home. Depending on the intensity of the outpatient program, patients may attend treatment daily or a few times a week.
Physician-Directed Medication Management
When a patient is prescribed medication for a chronic pain problem, there is a risk, however small, that her consumption of the medication might get out of hand in an attempt to alleviate the discomfort caused by the pain. This is the start of many stories of prescription drug abuse, which is why a number of doctors take a hands-on approach to monitor their patients’ intake, or to ensure patients’ compliance.
The physician directing the management of medication allows for explicit communication between the doctor and patient, to prevent (or, at the very least, minimize) the chance of the patient going off the rails with their prescribed medication.
Process groups are a form of group therapy, where between five and 10 people get together under the moderation of a trained therapist, to exchange stories, struggles, and perspectives of the addiction problem that has brought them together. The therapist will also encourage the participants to offer support, encouragement, and feedback in the safety and confidentiality of the process group.
In doing so, patients learn self-awareness and how they can relate to others, which can make a significant difference in helping them resist the temptation and compulsion to misuse drugs or alcohol in the future.
As the name suggests, a psychoeducational group teaches participants about their common mental health disorders and how they can cope with those disorders in healthy and positive ways. Some psychoeducational groups consist of participants with different diagnoses, and the focus of the group is learning practical life skills that are applicable to all their respective situations.
Psychoeducational groups are typically moderated by counselors or mental health professionals.
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(Rapid) Trauma Resolution
When a patient is suffering from panic disorders or anxiety attacks as the result of a traumatic event, one of the treatment options is what is known as rapid trauma resolution. It works by eliminating the negative effects of past experiences, as well as the skewed and misguided beliefs that patients unwittingly attach to those experiences. With the guidance of a counselor, patients retell the story of their trauma without experiencing the pain or shock of the trauma as they do so.
As this happens, the therapist identifies “ghosts,” or the specific effects that the trauma has had on the patient. As each ghost is identified, the therapist helps the client develop tools and skills to treat them effectively and objectively
The end result is that patients learn how to talk about their trauma, how to stay in a healthy and present frame of mind, and how to keep their focus when they might previously have turned to substance abuse to mitigate feelings of panic and stress.
Relapse prevention is a form of therapy that looks to identify and prevent situations in which a patient might be prone to falling back to their addictive behavior after treatment. Preventing relapse entails developing a plan to maintain sober behavior and sober thinking, even in the face of temptation, pressure, frustration, or isolation. The plan usually involves integrating coping skills and emotional support into daily behavior, so that when challenging or difficult situations present themselves, the patient has a number of healthy resources to fall back on.
One of the main elements of relapse prevention is the addict’s acknowledgement that coping with the craving for drugs or alcohol, while maintaining sober behavior, will eventually reduce the craving.
Residential treatment involves a patient living in a health care facility while they receive around-the-clock treatment for their substance abuse or mental health disorder. Some residential facilities are unique to the patients they welcome – for example, there are residential facilities specifically for women, for children, for teens, etc.
Residential care allows for comfortable and relaxed living conditions, with therapeutic structure and discipline that are vital for the patient’s recovery and treatment, which is facilitated by full-time staff, counseling sessions, and socializing with other residential patients.
Sober living entails knowing how to focus thoughts and behavior in an environment that might not be conducive to remaining abstinent. Fortunately, patients have a number of avenues by which they can reintegrate into society at large and still maintain their sobriety.
For example, sober exercise is a very popular approach for addicts looking to engage with other likeminded people in an activity that gives them a rush of adrenaline and endorphins but without the fear of relapse.
Similarly, while the rave scene is infamous for its connections with dangerous drug use and rampant alcohol consumption, a new “sober rave” movement offers participants the chance to listen to music and energetically dance with other clubbers – at 7 a.m., with absolutely no drinking or Ecstasy involved.
Of course, some patients are not yet ready to take those admittedly difficult steps, which is why there exist sober living facilities. Such environments allow the addict to enjoy the safety and control of rehabilitation for a bit longer, while gradually exposing them to the real world that is outside the umbrella of treatment. Recovering addicts are required to have jobs, consent to random room searches for evidence of hidden drug consumption, and attend weekly therapy meetings in order to remain in the safe haven of a sober living area. Despite some issues, sober homes are generally effective; a study that was published in the Journal of Substance Abuse Treatment found that “residents of [sober living homes] made improvements in a variety of areas.”
One element of an intensive outpatient program is what’s known as sub-acute detox. As the name implies, it is a level of detoxification that is not as rigorous as the traditional treatment approach. This method may be employed if there is a concern that the patient is so susceptible to addiction that giving them traditional detox medications, like benzodiazepines to ease anxiety in withdrawal, might make the patient dependent on the medication to cope with all anxiety-related feelings. The reasoning behind this is that as an addict is weaned off her drug of choice, her brain is primed and desperate to find another catalyst for the dopamine highs she experienced while high or drunk.
Treatment staff members may be of the opinion that instead of a patient presenting as an alcoholic or an opiate addict, the patient is instead a candidate for “addiction syndrome.” If this is the case, the health care professionals involved may opt for sub-acute detox, eschewing the administration of standard prescription medication for fear that the patient is not yet at a point where she can tolerate the effects of even supervised drug use.
The 12-Step Philosophy
In the same way that addiction can be a terribly complicated issue, the emotional and social dynamic of treatment can also be a multifaceted process. To help patients understand their new sober identities in the world, aftercare support groups draw from the 12-Step philosophy of Alcoholics Anonymous.
Whatever a person’s addiction – be it to alcohol, drugs, gambling, eating, shopping, or sex – groups that espouse the 12-Step system encourage the person to admit that she is powerless to control her urges on her own. Instead, patients are encouraged to invest their recovery in, and draw power from, the concept of a higher power. Whether this higher power is God, the concept of God, or something that the patient sees as larger and greater than herself, depends on the patient and the nature of the group. Traditional 12-Step groups are often rooted in Christian concepts and philosophies, but there exist 12-Step groups for atheists, agnostics, and adherents of other faiths.
Another mission of the 12-Step philosophy is to systematically scrutinize the mistakes the patient has made as a result of his addiction(s), and go about making amends for those mistakes. This might cover making simple apologies for things said and done while high or drunk, repairing relationships damaged by the addiction, or otherwise attempting some form of restoration.
Perhaps most importantly, the 12-Step method offers recovering addicts a safe place where they can express the frustration (and occasional failure) of trying to maintain their sobriety, to an audience who fully understands what that means. Other participants also know how to provide solidarity and insight in a way that will make sense to the patient. One of the tenets of the 12-Step philosophy is that experienced members mentor newer members, who in turn adopt the role for other newcomers, thereby continuing the cycle of healing and helping.
Simply put, “use” is any time someone consumes alcohol or drugs. However, “use” is not always the first step toward an addiction: most people can have a drink without becoming alcoholics, and many people can use drugs without developing an addiction. There is always a risk of addiction, which should be considered before using any controlled substance (or even prescription medication).
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