GPSolo Magazine - October/November 2006
What to Expect in Treatment
More than ever before, the concept of “treatment” for chemical dependency is in the public eye. We hear about celebrities being sent to treatment—formerly called “rehab.” We watch chemically dependent individuals go through the intervention process on television, as family members desperately urge them to go to treatment. Although what we see on television may suggest a nice rest in a bucolic location, punctuated by long walks, gentle counseling, and friendly softball, this is far from the real picture.
The basic goals of all treatment are the same: to provide individuals with a safe, sheltered environment—away from their chemical substances and addictive triggers; to break through the denial and defense mechanisms of their addiction; to educate them about the disease of addiction and thus reduce shame; to provide them with the skills to return to their jobs and families without relapse; and to introduce them to a support network that nurtures their recovery. Addiction-specific modes of treatment may vary somewhat depending on the substance being abused (gambling, eating disorders, sexual addiction, etc.); this article provides a general overview of addiction treatment.
The realities of treatment and recovery are not one and the same, even though treatment is a very important part of the recovery process. Completing a formal treatment component is not the end for anyone with an addiction problem but rather the start of a lifelong process of recovery. The recovery process takes place over time and often in specific stages. It is more than abstinence: It is the door to a fully functioning, healthy life.
The average law practitioner might wonder how this is relevant to him or her. Certain practice areas consistently are linked to clients struggling with issues of chemical dependency: domestic relations, bankruptcy, and criminal law; debtor/creditor issues; and even personal injury and workers’ compensation cases. Forty-seven percent of workers’ comp accident cases are alcohol- or drug-related. Two-thirds of all domestic violence cases involve alcohol or drugs. Nationwide in the early 2000s, some 70 percent of those arrested tested positive for alcohol or drug use. Sadly, these issues are not limited to our clients but extend to our colleagues in the legal profession. Studies done more than ten years ago in Arizona and Washington showed that 19 percent of licensed lawyers were addicted to alcohol, and 3 percent to cocaine or other drugs. At least one in five lawyers abuses alcohol or drugs. This is twice the rate of the general population; it deserves our attention and concern.
How is an individual’s need for treatment determined? Generally, he or she is given a brief screening instrument that asks simple questions about patterns of alcohol and drug use. These questionnaires are short, easy to remember, and can be self-administered in a few minutes. The Tolerance-Annoyance scale, or T-ACE questionnaire, is widely regarded as the most effective screening instrument for alcohol use in both men and women. It asks only four questions: (1) How many drinks does it take to make you feel high? (2) Have people annoyed you by criticizing your drinking? (3) Have you ever felt you ought to cut down on your drinking? (4) Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?
Affirmative answers to the final three questions each score one point. An answer of two or more for the first question scores two points. A score of two or more on this test generally indicates that the individual has a problem with alcohol.
If the screening is positive, the next step is a formal assessment. This should be administered by a certified alcohol and drug counselor, a doctor (or board-certified physician specializing in addictions), or a psychiatric nurse practitioner who has an understanding of addictions. The American Society of Addiction Medicine (ASAM) has formulated guidelines to be used in determining the best treatment options for the individual. The ASAM PPC-2R (patient placement criteria) evaluates the person according to six possible dimensions: acute intoxication/withdrawal potential; biomedical conditions and complications; emotional, behavioral, or cognitive conditions and complications; the patient’s readiness to change; potential for relapse, continued use, or continuing problem; and the patient’s existing environment for recovery. The results aid the practitioner in determining the level and type of treatment that best matches the individual’s needs and problems. A treatment recommendation using this scale is usually required by both the treatment center and the insurer providing coverage, if any.
Treatment centers offer a variety of settings: inpatient, hospital-based programs; short- and long-term residential programs; or outpatient programs the individual attends during the day or evening if he or she is able to keep working. Most programs also provide a combination of therapies, such as pharmacological therapy to treat certain addictions (for example, administering methadone or buphenorphine to wean someone from opiate addiction, or naltrexone or acamprosate calcium to treat severe alcoholism or drug addiction); psychological therapy or counseling; education and social learning theories; and nontraditional healing methods such as meditation and acupuncture. Treatment plans may extend over weeks, months, or years, depending on the severity of the problems and level of structure needed to support an individual’s recovery. In addition, concurrent medical disorders such as cirrhosis, HIV/AIDS, mental illness (especially depression), or serious physical incapacities must be addressed. Attendance at 12-Step and other support groups may also augment treatment or post-treatment recovery.
Lawyers in general are high-maintenance professionals with high-maintenance clients, and the suggestion that a lawyer enter a 30-day residential treatment program is often met with disbelief: “I can’t be away from my office/cases/trial/clients that long,” insist sole practitioners and lawyers in large firms alike. Here, the counselor usually explains that a diagnosis of addiction is much like that of any other health emergency. An attorney stricken with a heart attack or injured in a car accident might need long-term care, and arrangements would be made to inform clients and assign someone to look after open cases. Treating addition is no different. The local LAP often has much experience in coordinating emergency practice management.
What should the lawyer expect during residential treatment? The initial concern is to medically stabilize the patient, which may include a period of detoxification. Although the average person assumes that withdrawal from drugs is dangerous, many do not know that withdrawal from alcohol without medical supervision can be fatal. Detoxing clients are cared for on a closed medical unit, away from the general treatment population. After detox, the client receives a room assignment within the main population—men with men, women with women—and participates in a daily routine that includes chores, individual and group counseling, quiet time, meals, and group activities. (See sidebar “Sample Treatment Schedule” on page 28.)
Many treatment facilities include a “family week,” where spouses, children, parents, siblings, and so on can receive information about chemical dependence and recovery and in some cases begin the process of talking about existing conflicts in a safe, structured setting. Because relapse is common (although not inevitable) for even those who attend structured treatment, clients and family discuss vulnerabilities and receive a relapse prevention plan. Because predictable and identifiable warning signs begin long before a person returns to using alcohol or drugs, intervention is often possible. (See the sidebar “Relapse Warning Signs” on page 29.)
When a client is ready to leave the treatment center, he or she receives a final, personalized discharge plan that was created with the client’s input and feedback. Based on the client’s physical, psychological, and sociological needs, the plan describes specific problem areas the client should watch for, as well as goals and specific steps for achieving those goals over a clear time frame. It also contains a section reaffirming the ways in which counselors, family members, and support groups can or will assist the client.
Unfortunately, costs for chemical dependency treatment have kept step with the health care industry as a whole, and it is an expensive commitment. Assessment counselors try to match the client’s resources with affordable treatment options, adding what the client can pay to what insurance will cover (if applicable). A 30-day treatment program might vary from $3,000 to $30,000. Any balance remaining after insurance payments is the client’s responsibility, and most centers will work with clients to come up with a realistic payment amount and schedule. The greatest challenge for LAP staff, employee assistance professionals, or family members trying to get help for a loved one is deciding how to pay for treatment that might be long term or require ongoing medical support. Some states provide free or low-cost public treatment programs, and although they often have waiting lists, many of the candidates have unfortunately returned to their habits by the time a space becomes available, so the lists can move quickly. Some LAPs are partially funded by charitable foundations that provide treatment loans or grants based on need. Although the expense is daunting, recovering clients and family members generally agree the cost of treatment is worth it.
Treatment works. The Federal Drug Abuse Treatment Outcome Study (DATOS, 2003) is the largest study of its type ever performed, having examined more than 10,000 addiction treatment clients, with follow-ups at one year and five years. A follow-up study showed a 50 percent reduction in overall drug use by those who had attended residential treatment, and a 61 percent reduction in criminal behavior, with stable results five years later. The government requires treatment centers obtaining state or federal funds through block grants or Medicare payments to use scientifically proven methods to ensure the programs have a high cost-benefit ratio.
Treatment reunites families, saves lives, and restores damaged careers; impaired lawyers who receive treatment also save malpractice insurers the price of successful cases and reduce disciplinary complaints. The Oregon Attorney Assistance Program did a study of 55 lawyers in recovery to compare malpractice/disciplinary statistics from five years before they were treated and five years after recovery. The lawyers had a total of 83 malpractice claims before treatment versus 21 claims in the five years after their recovery. Disciplinary complaints filed against the same 55 lawyers in the five years prior to recovery numbered 76, whereas complaints after recovery totaled 20. Treatment saved the malpractice carrier $200,000 annually—from only 55 lawyers. Savings for the disciplinary system were not computed, although the 20 complaints received after the lawyers were in recovery were all dismissed. Treatment yields undeniable benefits—not only for those who attend it, but for the system as a whole.
Relapse Warning Signs
Recovery is more than just not drinking or using. It is a holistic process. Relapse can begin when the process of recovery is stalled, and old ways of thinking—along with the behaviors that fuel those old beliefs—return, building enough chaos in the addicted individual’s life until returning to chemical use seems like a logical option.
The relapse process has identifiable patterns and can be interrupted before alcohol or drug use resumes. Observation and intervention by friends and associates is helpful. Often, the addicted individual does not even realize that he or she is headed for a relapse.
Below are some warning signs:
• Sensitivity to stress, disturbed sleep, difficulty concentrating or remembering things, volatile emotions (these may be signs of post-acute withdrawal syndrome, or PAWS, which may occur in recovering individuals for six to 18 months after abstinence from their substance of abuse)
• Increased use of caffeine or nicotine (particularly if use of those substances had previously stopped)
• Skipping or stopping recovery support activities (group meetings, contact with sponsor or recovering friends)
• Isolation or denial, not talking about feelings or problems, or not acknowledging them
• Engaging in other compulsive behaviors, such as eating, shopping, gambling, exercising, working, and Internet use
• Avoidance or defensiveness when confronted (“Everything’s fine—it’s none of your business”)
• Depression, feelings of hopelessness (“Why bother?”)
• Idealized thoughts about alcohol or drug use, minimizing consequences (“That drink looks good. I had some fun times getting high. My problem wasn’t that bad. Using just once would be okay. I’d be able to control it this time.”)
• Chemical use (even if a different substance) followed by all-or-nothing thinking (“I’ve already blown it, so why ask for help? It’s too hard. I can’t do recovery. What’s the use?”)
For more information on how to recognize and intervene in the relapse process, see Staying Sober: A Guide for Relapse Prevention by Terence T. Gorski and Merlene Miller.
Michael J. Sweeney, JD, CADC III, is an attorney counselor with the Oregon Attorney Assistance Program; he can be reached at firstname.lastname@example.org. Meloney Crawford Chadwick, JD, CADC III, NADC II, is an attorney counselor with the Oregon Attorney Assistance Program; she can be reached at email@example.com.