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Always the First Step: Medical Detox
Regardless of the defining modality, high-quality treatment programs begin with medical detox, which is a medically supervised detoxification process that allows all traces of a drug to leave the body so that brain function can begin to return to normal. During medical detox, medications are administered as needed to alleviate the intensity of withdrawal symptoms and shorten the duration of detox.
It’s important to note that detox only addresses the physical dependence on a drug and does very little to help an individual overcome an addiction, according to the National Institute on Drug Abuse.(1)This is because addiction is far more complex than dependence and nearly always has a number of underlying causes that may include trauma, mental illness, family dysfunction or stress.
Detox only addresses the physical dependence on a drug and does very little to help an individual overcome an addiction.
Treatment Settings: Residential and Outpatient
The most important initial consideration for choosing a treatment program is matching a client’s needs to the best treatment setting for that individual(2). The goal is to start by placing a client in the least restrictive environment that will be safe and effective and then move the client along a continuum of care as they advance.
From most to least restrictive, the most common treatment settings for addiction rehab are long-term residential, short-term residential, intensive outpatient and standard outpatient treatment.
Long-Term Residential Treatment
Long-term residential treatment is a six- to 12-month inpatient treatment modality that focuses intently on an individual’s social and psychological issues and works to help clients develop personal responsibility and accountability. Therapeutic communities (TCs) are the most common type of long-term residential treatment program. In the TC, the focus is on resocializing clients by creating a successful community in which everybody, including residents and staff, has a role in helping others succeed in treatment.
The focus on therapeutic communities is to resocialize clients by creating a successful community in which everybody has a role in helping others succeed in treatment.
TCs are highly structured and utilize a wide variety of therapies to address all of a client’s issues that underlie the addiction. These therapies help clients:
- Synthesize their experiences.
- Evaluate their belief system and discard false beliefs in favor of truth.
- Replace harmful thoughts and behaviors with healthier ones.
- Develop a higher level of self-esteem and self-efficacy.
- Find purpose in life.
TCs often include other services to meet individuals’ needs, such as vocational therapy, educational or legal assistance or access to medical or mental health care.
The benefits of long-term residential treatment include:
- 24-hour supervision and support
- The opportunity to delve deeply into a variety of issues to improve one’s quality of life and sense of well-being
- The complete absence of opportunities to use drugs
- The opportunity to develop healthy relationships with others in the community and develop missing social skills
- An intensely structured environment to help clients develop healthy habits
The down sides of long-term residential treatment are the high cost and the need to be away from home, work or school for up to a year. However, many insurance plans cover long-term treatment, and making the commitment to long-term treatment will dramatically improve the chances of long-term recovery once the program is complete.
Long-term residential treatment programs are ideal for people who:
- Have a long history of drug abuse and addiction
- Tried short-term residential or outpatient treatment with poor results
- Have a serious co-occurring mental illness or a significant lack of self-care or social skills
- Don’t have a safe and supportive place to live
- Have little support in the community
Short-Term Residential Treatment
Short-term residential rehab programs provide relatively brief treatment in an intensive three- to four-week program. These programs are generally based on a modified 12-step approach and strive to help individuals develop a strong foundation for recovery by beginning to address the complex issues that led to the drug abuse and addiction.
Short-term residential treatment is followed by a highly individualized aftercare plan that draws on the momentum and motivation gained in treatment to help clients successfully navigate early recovery in the community. Full engagement in the aftercare plan is essential for success.
A typical plan will include ongoing therapy, participation in a 12-step or similar support program and regular meetings with a case manager who evaluates for changing and emerging needs that need to be addressed. Other components of the aftercare plan are added based on need and may include:
- Time in a sober-living facility
- Educational assistance
- Legal assistance
- Housing assistance
- Vocational training
- Parenting classes
- Transportation help
- Monitoring of any medical or mental illnesses and the medications used to treat them
The benefits of short-term residential treatment include:
- A lower price tag than long-term residential treatment
- A safe and structured environment for addressing a variety of issues
- The opportunity to develop missing social and personal skills through intensive therapy
- Less time away from work, school and other responsibilities
- The aftercare plan, which is an integral part of treatment that helps individuals successfully reintegrate into the community with the highest possible level of support
Short-term residential programs are ideal for people who:
- Don’t yet have the intrinsic motivation necessary for successful recovery
- Need a high level of support at the beginning of their recovery journey
- Need 24-hour supervision initially to successfully maintain abstinence
Outpatient and Intensive Outpatient Treatment
Outpatient treatment and intensive outpatient treatment both take place during the day or evening hours while a client lives at home and continues to work, attend school or care for the family.
Intensive outpatient treatment generally involves at least nine hours per week of programming. A typical intensive outpatient treatment program will require attendance for three to eight hours of programming a day for five to seven days each week. As a client progresses, the frequency and length of sessions are reduced.
Outpatient treatment typically involves less than nine hours per week of programming, which generally includes once- or twice-weekly group, individual and family therapy sessions as well as other services as needed.
The benefits of outpatient treatment include:
- The ability to continue working, attending school or taking care of the family while in treatment
- A lower cost than short- or long-term residential treatment
- The ability to put new skills and strategies to use right away in real-world situations
Outpatient treatment is ideal for people who have:
- A high level of intrinsic motivation to recover
- A safe place to live
- The ability to travel to and from the program site
- A high level of support at home and in the community
The Treatment Approach: Holistic is Essential
The Substance Abuse and Mental Health Services Administration stresses that there is no single pathway to recovery that’s successful for every individual(3). Some approaches to treatment focus on biological factors of addiction, while others focus on the psychological aspects. Still others adhere to a sociocultural model that focuses on environment and interpersonal relationships.
There is no single pathway to recovery that’s successful for every individual.
Regardless of the specific focus of a treatment program, the most successful programs take a holistic approach to treatment that addresses issues of mind, body and spirit, according to SAMHSA, which has identified four major dimensions of recovery that treatment should strive to address, regardless of the modality:
Health. Addiction takes a toll on both physical and mental health, and achieving a healthy body and mind is central to successful recovery. Clients in a successful treatment program will work to overcome or manage any medical or mental health issues, and they’ll learn to make informed, healthy lifestyle choices that support a high quality of life and a strong sense of well-being.
Home. Having a safe, stable place to live is crucial for successful recovery. For those who don’t, inpatient treatment is essential. Services will likely include family therapy to help improve the functioning of the family system or helping an individual find a safe, stable place to live once treatment is complete. One housing option for post-treatment living is a sober living facility, which offers a safe, supportive and lightly structured environment during the early months of recovery.
Purpose. Having a purpose in life is central to a positive treatment outcome. Conducting meaningful daily activities, such as maintaining employment, volunteering, attending school or taking care of the family, is critical for promoting personal satisfaction and fostering a sense of belonging. Recovery is most successful when an individual also has the income and resources to fully participate in society.
Community. Healthy relationships are critical for successful recovery. Having healthy relationships and a strong social network ensures an individual has the support, love and friendship needed to facilitate healthy lifestyle choices and maintain ongoing abstinence.
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Components of Treatment: Traditional Treatment Therapies
Since every journey to long-term recovery is different, a high-quality treatment program will offer a wide range of treatment therapies, although not every client will engage in every type of therapy. An individual’s personalized treatment and recovery plan will include the therapies that will effectively address their specific needs and issues.
An individual’s personalized treatment and recovery plan will include the therapies that will effectively address their specific needs and issues.
High-quality programs utilize only research-based therapies, whether traditional or complementary. Traditional treatment therapies are those that are tried-and-true and which have proven time and again in clinical studies to be effective for treating a range of illnesses, including addiction.
The National Council on Alcoholism and Drug Dependence calls addiction a “family disease” because it indelibly affects each family member and the family as a system, leading to dysfunctional behaviors and unhealthy relationships.(4) Family therapy is a cornerstone of treatment because it helps to restore familial relationships and improve the function of the household, two major factors in successful recovery.
Cognitive-behavioral therapy, or CBT, is another cornerstone of treatment. CBT leads individuals to evaluate their thoughts and behaviors, identify those which are self-destructive and work to replace harmful ways of thinking and behaving with healthier ways for far-reaching, meaningful change.
Motivational Enhancement Therapy
Motivational enhancement therapy, or MET, helps those who are ambivalent about recovery develop the motivation to change. MET involves up to four sessions, during which the therapist leads the client to make self-motivational statements and design a plan for change. MET is a successful way to improve engagement in treatment and reduce drug abuse.(5)
12-Step Facilitation Therapy
12-step facilitation therapy operates under the assumption that addiction is a disease with biological, psychological and spiritual underpinnings, which are all addressed as an individual progresses through the 12 steps of recovery.
An article published in the journal Recent Developments in Alcoholism cites a study finding that people who continuously participate in a 12-step program like Alcoholics Anonymous or Narcotics Anonymous are around six times more likely than their non-participating counterparts to successfully maintain abstinence for at least a year after treatment ends.(6)
Relapse Prevention Therapy
Relapse prevention therapy is a psychoeducational undertaking that helps individuals understand the mechanics and stages of relapse, recognize the early signs and develop a toolkit of skills and strategies to cope with stress, cravings and other potent triggers that can quickly lead to relapse.
Moral Reconation Therapy
Moral reconation therapy helps individuals with a low level of moral reasoning to develop higher-level reasoning skills that consider personal and societal well-being and the greater good when making a decision. Clients learn to be honest with themselves and others, evaluate their personal relationships, form a positive self-identity, identify a higher purpose in life and work on setting and reaching personal goals.
Dialectical Behavior Therapy
For those who struggle with chronic suicidal thoughts, self-harm and borderline personality disorder, dialectical behavior therapy, or DBT, helps them accept and validate, rather than struggle with, uncomfortable thoughts, feelings and behaviors that can quickly lead to substance abuse. Mindfulness and relaxation are elements of DBT that promote resisting self-destructive urges and making better lifestyle choices. Clients develop a toolkit of coping skills for high-risk situations and other potent triggers.
Components of Treatment: Complementary Treatment Therapies
A holistic approach to treatment involves a balance of both traditional and complementary therapies to address various aspects of a range of issues underlying an addiction. Complementary therapies commonly used in treatment programs lie outside the mainstream but are shown by research to be effective on many fronts when treating addiction.
Experiential therapies involve hands-on activities to help clients work through obstacles, experience success, make important connections between thoughts and behaviors and develop a higher level of self-esteem. Common experiential therapies include working with horses, camping in the wilderness and engaging in music therapy or art therapy. These activities help to increase engagement in treatment, decrease denial, reduce ambivalence toward recovery and increase motivation to change.(7)
Since stress is a major trigger for relapse, a great deal of attention in treatment is devoted to stress reduction therapies and techniques. Massage therapy has been shown in numerous studies to reduce stress levels and ease depression and anxiety. Researchers believe this is because it reduces levels of the stress hormone cortisol and lowers blood pressure as well as increases levels of feel-good brain chemicals like serotonin and oxytocin. Many studies also point out that massage therapy promotes body awareness and produces strong feelings of comfort and connection for a higher sense of well-being.
Massage therapy promotes body awareness and produces strong feelings of comfort and connection for a higher sense of well-being.
Acupuncture is a 3,000-year-old Chinese technique that involves inserting thin needles through the skin at strategic points to relieve particular symptoms, including insomnia, stress and those associated with anxiety, depression and PTSD. The University of California at San Diego’s Center for Integrative Medicine asserts that acupuncture helps to restore optimal function to the various systems of the body for better overall health and a higher sense of wellbeing—important factors in long-term successful recovery.(8)
Meditation is fast becoming a mainstream complementary therapy for a wide range of illnesses. Meditation dramatically reduces stress and helps the brain and body respond to stress more effectively(9). A study published in JAMA Internal Medicine found that anxiety and depression can be effectively treated with meditation(10). Harvard Medical School notes that meditation helps individuals identify destructive thought patterns and replace them with healthier ones(11).
Yoga combines breath control and movement to promote physical and mental flexibility, strength and balance for better overall health and a higher sense of well-being. Yoga is especially helpful for relieving stress by reducing the body’s responses to stress such as an elevated heart rate and muscle tension(12).
Special Considerations in Treatment: Trauma and Mental Illness
For some, a standard treatment program is inadequate because it fails to fully address some of the more complicated issues that often occur with addiction. The wide range of treatment modalities include programs that are designed to address very specific issues or treat certain populations.
Exposure to trauma, particularly in childhood, is inextricably linked to substance abuse. A study published in the journal Depression and Anxiety explains that early trauma—such as sexual or physical abuse or exposure to violence—affects the structures and function of the brain and may lead to cognitive deficits, substance abuse or mental illness later in life(13). The study points out that over 70 percent of adolescents in treatment for a substance use disorder had a history of trauma. A study published in the journal Psychiatry Services found that up to 80 percent of women in rehab have a lifetime history of sexual or physical abuse(14).
Additionally, people who have been a victim of or witness to a traumatic event as an adult—including first responders like police officers and EMTs—often suffer from post-traumatic stress disorder (PTSD), which causes symptoms like depression, anxiety, anger, nightmares and flashbacks. Many who suffer from PTSD abuse drugs or alcohol as a way of coping with negative emotions, combatting insomnia and nightmares or helping them forget the incident.
The Substance Abuse and Mental Health Services Administration stresses that a trauma-informed approach to treatment is essential for individuals with PTSD or a history of trauma(15). This approach can be implemented in any program, regardless of its overarching modality.
According to SAMHSA, trauma-informed care should:
- Understand the dramatic impact of trauma on an individual’s life and identify appropriate paths to recovery
- Recognize signs and symptoms of trauma
- Integrate knowledge about trauma into practices, policies and procedures
- Actively work to prevent re-traumatization
Around one-third of all people who have any type of mental illness and half of those with a serious mental illness also have a substance use disorder, and half of all people with a drug addiction also have a mental illness, according to the National Alliance on Mental Illness(16).
When a mental illness co-occurs with a substance use disorder, it’s known as a dual diagnosis, and successful treatment depends on addressing both disorders at the same time. Dual diagnosis treatment is a collaboration among treatment teams for both the substance use disorder and the mental illness. Treatment for the mental illness is administered in the context of the substance use disorder, and vice-versa. Treating just the substance use disorder but not the mental illness results in a very low success rate.
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The Bottom Line
Different modalities of treatment accomplish specific goals within a broader framework. SAMHSA stresses that no single modality is the right one, and that an individual’s treatment plan should consist of those modalities that specifically address relevant issues, needs and preferences.
To help guide the search for a high-quality treatment program regardless of modality, the National Institute on Drug Abuse has developed the Principles of Effective Treatment, which are 13 tenets that a reputable, high-quality rehab program will adopt to guide its approach to treatment.(17) These include the acknowledgment that:
- Addiction is a complex disease of the brain that affects behavior and brain function, and some changes persist long after treatment and lead to relapse.
- No single approach to treatment is right for every individual. Matching the modality of treatment to the individual is critical for ultimate success.
- Effective treatment addresses all of an individual’s needs, not just the drug abuse.
- Individual, group and family behavioral therapies are the most commonly used and successful forms of treatment.
- Medication is an important element of treatment for many people in recovery.
- An individual’s treatment plan should be continually assessed and modified based on changing and emerging needs.
- Co-occurring disorders are common, and treatment must be integrated for the best possible treatment outcome.
If you’re struggling with a substance use disorder, an addiction counselor or other mental health professional can help you choose the right modality for you to help ensure successful treatment and promote long-term recovery.
(1) Understanding Drug Abuse and Addiction: What Science Says. (2016, February). Retrieved from https://www.drugabuse.gov/publications/teaching-packets/understanding-drug-abuse-addiction/section-iii/7-medical-detoxification
(2) Treatment Improvement Protocols: Specialized Substance Abuse Treatment Programs. (1997). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK64815/
(3) Recovery and Recovery Support. (2015, October 5). Retrieved from http://www.samhsa.gov/recovery
(4) Family Disease. (2016, February 24). Retrieved from https://www.ncadd.org/family-friends/there-is-help/family-disease
(5) Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition): Motivational Enhancement Therapy. (2012, December). Retrieved from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/evidence-based-approaches-to-drug-addiction-treatment/behavioral-2
(6) Laudet, A. B. (2008). The Impact of Alcoholics Anonymous on Other Substance Abuse Related Twelve Step Programs. Recent Developments in Alcoholism, 18, 79-81. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2613294/
(7) Aletraris, L., Paino, M., Edmond, M. B., Roman, P. M., & Bride, B. E. (2014). The Use of Art and Music Therapy in Substance Abuse Treatment Programs. Journal of Addictions Nursing, 25(4), 190-196. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4268880/
(8) How Acupuncture Can Relieve Pain and Improve Sleep, Digestion and Emotional Well-Being. (n.d.). Retrieved from http://cim.ucsd.edu/clinical-care/acupuncture.shtml
(9) Marcus, M. T. and Zgierska, A. (2009). Mindfulness-Based Therapies for Substance Use Disorders: Part 1 (Editorial). Substance Abuse, 30(4), 263. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2818765/
(10) Goyal, M. et. al. (2014, March). Meditation Programs for Psychological Stress and Well-being. JAMA Internal Medicine, (174(3), 357-368. Retrieved from http://archinte.jamanetwork.com/article.aspx?articleid=1809754
(11) Corliss, J. (2014, January 8). Mindfulness Meditation May Easy Anxiety, Mental Stress. Retrieved from http://www.health.harvard.edu/blog/mindfulness-meditation-may-ease-anxiety-mental-stress-201401086967
(12) Yoga for Anxiety and Depression. (2009, April). Retrieved from http://www.health.harvard.edu/mind-and-mood/yoga-for-anxiety-and-depression
(13) Khoury, L., Tang, Y. L., Bradley, B., Cubells, J. F., & Ressler, K. J. (2010, December). Substance Use, Childhood Traumatic Experience, and Posttraumatic Stress Disorder in an Urban Civilian Population. Depression and Anxiety, 27(12), 1077-1086. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3051362/
(14) Cohen, L. R. and Hien, D. A. (2006, January). Treatment Outcomes for Women with Substance Abuse and PTSD Who Have Experienced Complex Trauma. Psychiatric Services, 57(1), 100-106. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3688835/
(15) Trauma-Informed Approach and Trauma-Specific Interventions. (2015, August 14). Retrieved from http://www.samhsa.gov/nctic/trauma-interventions
(16) Dual Diagnosis. (n.d.). Retrieved from https://www.nami.org/Learn-More/Mental-Health-Conditions/Related-Conditions/Dual-Diagnosis
(17) Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition). (2012, December). Retrieved from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/principles-effective-treatment