Let’s meet Doug. Doug has a wife and a young child, a dog, and a job in IT. Doug’s a responsible dad, an attentive husband, and he even just got a promotion at work. He’s never had any trouble with substances in the past, and would describe himself as a casual drinker. On the surface, Doug appears to be doing really well in his life. Sure, there’s the weekend parties where he drinks too much and his wife needs to drive home, and sometimes after work Doug goes out with friends and drinks enough that he needs to catch a cab home, but nothing has really raised flags that he has a serious problem.
All this changes when his wife Shelly finds some cocaine in the sock drawer. Her mild annoyance that he drinks too much sometimes on the weekends, turns into a real concern that something is wrong. Shelly talks to her friends and they tell her Doug is clearly an alcoholic and an addict, and that he needs to go to rehab or start going to AA meetings. Even more upset she approaches Doug and tearfully accuses him of being an addict and says she thinks he needs to go to rehab. Doug insists that the cocaine was just introduced by a work friend and he’s only done it a few times. He reminds her of how well he is doing at work and that she is over-reacting.
Shelly’s torn . . . on one hand she’s being told that Doug’s an addict/alcoholic that she shouldn’t trust and that he needs rehab. On the other hand Shelly’s known Doug for years and years, and doesn’t see him that way at all. Can she trust him? Can she trust herself? Is rehab the answer? Does he need to go to AA?
This scene is an all too familiar one for many people who find out that their loved one’s substance use is more than they thought it was. The first reaction is often to panic and assume the worst…and this is unfortunately confirmed by the outside world and people’s immediate assumptions about substance users (i.e., they lie and are in denial). The reality is that most substance users do not need rehab and will never go to an AA meeting. And they can still get better! In fact, insisting that they go to rehab or start going to self-help meetings may actually slow the process of change rather than help it along.
Why are rehab and self-help meetings the immediate suggestion? First, for many people they have been life-saving options. And these people like to talk about their experiences and are highly motivated to help other people find the same path to change. This is a really nice thing! But it is only one version of the change process and there are many, many more. Rehab and self-help meetings also appear in movies and TV shows and have even been the treatment of choice for the court systems. Odds are, if you are a lay-person in the United States, you have heard about these options and very little about the multiple other pathways to change that are supported by years of scientific evidence of effectiveness. At CMC we want people to know about all the options so that you can be an educated consumer and find the best option for you and/or your family.
Below is a primer summarizing different types of support that might be helpful to you or a loved one when trying to make changes in substance use.
Self-Help Meetings: These meetings are free and run by non-professionals. They includes AA, NA, SMART Recovery, Women for Sobriety, and more and all hold to the principles of the larger organization. SMART and Women for Sobriety are a little different in that they have volunteer facilitators (they are not professional therapists) with varying degrees of training. Because they are free and widely available (especially AA, NA etc), self-help meetings, are often the first options people think about when suggesting support options.
All of these organizations have different philosophies about how to approach the problem of addiction and behavior change. It is important to do your research and try multiple options so that you can find one that is closely aligned with your values and goals. Each meeting tends to have it’s own character (because they are all made up of different groups of people!) and the goal if you choose this type of support is to find one that works for you.
Individual/Group Therapy: While many therapists work with substance users, it can be important to ask about the treatment “orientation” or the level of training they have in the best evidence-based practices for substance use disorders. The best treatment approaches are often more skills based, with an emphasis on building an understanding of what kinds of things in your environment trigger you, how to handle triggers and cravings in the moment, and a focus on building skills to help prevent a relapse to old behaviors.
Don’t be afraid to ask treatment providers you are considering working with a lot of questions! It’s worth doing your due diligence as providers have a range of orientations, fees, level of experience and training. The most effective treatments right now are Motivational Interviewing (MI), Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), and the Community Reinforcement Approach (CRA). For families, the Community Reinforcement and Family Training approach (CRAFT) is a very effective treatment that improves the well-being of the family member and reduces substance use in the person using drugs or alcohol. Unfortunately, lots of providers have realized that saying they do these treatments is a good selling point. It is important to ask how and where they were trained in these approaches and what kind of ongoing supervision they received in them.
Often times it is crucially important to get medication support when you are trying to address a substance use problem. Again, psychiatrists have a range of experiences and training so it is important to look for those with specific training in addiction. Addiction psychiatrists have more intimate knowledge of substance use, treatment modalities, and a more nuanced understanding of how to prescribe medications to someone with a substance history. It also helps to find a psychiatrist who will collaborate with the rest of your “team” (therapist, sober coach, group program etc) and communicate about any changes in medication etc..
Intensive Outpatient Programs (IOP): These are a collection of group and individual treatments that create a whole treatment program that can be done in an outpatient setting. Ranging from 3 – 6 hours daily, anywhere from 3 – 7 days per week, IOPs will often include some skills building, some 12-step “step work” (depending of the orientation of the practice providing the treatment), some individual meetings, and more. They range in quality and price, and in their focus on skills building vs. step work. For a more rich experience, try and find a program that has specific skills building groups, has individual treatment weekly with a licensed therapist, and will work closely with addiction psychiatrists.
Sober Coaches/Companions: Sober coaches work are “out in the world” with you. They can be with you in your home, office, when traveling etc and can help you deal with the challenges that come with making significant life changes. For example, they can help someone who is depressed or socially anxious to get up and get to appointments and help navigate potentially risky situations (like social events) without using.
While these supports can be really helpful they are not a “well monitored” professional field. A huge range of people can call themselves a sober coach as it is currently an unlicensed field (hopefully this will change sometime soon). Many of them are “in recovery” themselves and have made it their job, literally, to help others in this way. Some have social work degrees, some do not. It’s important to ask about their credentials so that you really know who you are getting, and what kind of training (if any) they have. You can also ask to talk with treatment providers they have worked with or previous clients in order get a sense of how they work. Additionally, their fees vary (e.g., by the day, by the hour) and are not typically re-imbursable by insurance so the financial aspects of this type of support need to be considered.
Sober Living: Sober livings are supervised living situations where people live in a house with other people who are all working to abstain from substances. They can range in quality, both quality of living and quality of support, and can range greatly in price. There is usually very little or no “treatment” that goes on in-house, although many will provide a sober coach (often at an additional cost) and will require people to attend daily 12-step meetings.
Inpatient Rehab: This is the highest level of care, and in most cases should be saved until after a person has tried some of the lower-level outpatient treatment options listed above. Similar to Intensive Outpatient Programs, these rehabs will range in quality and price, orientation (12-step versus Evidence Based approaches) and in how much contact you will have with a highly trained individual therapist. For an excellent book on all things rehab (including what to look for and what questions you should be asking), we recommend Anne Fletcher’s Inside Rehab . It is a non-biased review of the rehab world and gives consumers all the information they need to find the place that’s right for them.
There has been a major shift recently towards evidence based practices and rehabs have started to move towards having more evidence based treatment options available to clients. That said, it is important for clients to ask about how those treatments are presented, who runs those groups, where they were trained, etc. Many more rehabs are calling themselves “evidence-based” than are necessarily practicing it! So ask lots of questions!
Understanding your treatment options is the first and most important step to getting yourself on the path to long-lasting change. Maybe Doug just needs to have a few sessions with a therapist trained in Motivational Interviewing to help him assess whether his substance use is a problem or not. Maybe his wife can come for a few sessions to give feedback and offer support (and get some for herself!). Maybe he will on his own decide he wants to reduce his drinking because he does not want to upset his wife. All of these are very real ways that people decide to change…without ever going to rehab or a meeting. As you think about change (for yourself or a loved one), be open to all options. You never know which will work for you.