[acb-hsp] FW: Good info. May want to share with others.

[Baracco, Andrew W]

Can't recall if I already shared this.

Subject: Good info. May want to share with others.

 

Issue Date: September-October 2011, Posted On: 10/5/2011

Help for the chronic relapser
Success in treatment requires time and a high degree of accountability
by Heidi Voet Smith, LPC 

 

Heidi Voet Smith, LPC

Treatment providers, family members and the general public often are
baffled when individuals who have received good addiction treatment
continue to relapse. As the clinical director at Burning Tree Recovery
Ranch in Texas, I serve only clients with a history of chronic relapse.
Through my experience working with this population, I have discovered
that this type of addict is not as mysterious and complex as many might
think. In fact, the chronic relapser is quite predictable-and treatable.

Through this work, I have come to develop an intimate knowledge of the
defining features in the profile of chronic relapsers.

Profile of the chronic relapse

Numerous failed attempts at sobriety or a return to drugs/alcohol after
a substantial period of sobriety. While this is a simple and obvious
criterion of a chronic relapser, the distinction of an individual who
has attempted sobriety and failed is important. Many addicts have a
lifetime of drug and alcohol abuse but have never actually attempted to
get sober. What makes chronic relapsers distinct is that they have tried
and failed. 

 Unable to maintain sobriety despite having a wealth of knowledge about
addiction and recovery. Often, chronic relapsers know enough about the
disease concept, the 12 Steps, relapse triggers, the neurological impact
of drugs, and family roles to teach classes on substance abuse at a
treatment center. However, they have no experience in applying this
knowledge to their lives in a way that creates lasting sobriety. Their
wealth of knowledge is something that chronic relapsers will often use
as a weapon when loved ones attempt to intervene.

Continued substance use despite significant, severe and repeated
consequences. This is the baffling and insane feature of addiction in
general, but particularly with chronic relapsers. Despite loss of
children, loss of family, homelessness, seizures, heart attacks,
diseases, prostitution, incarceration and overdose, chronic relapsers
continue to drink and use drugs. While they may have an intense and
honest desire to stop using, they are powerless to make that choice.

Chronic relapsers often feel hopeless that they will ever find lasting
sobriety. Addicts in their first attempt at sobriety, whether in
treatment or a 12-Step program, often possess great hope and excitement
about a new life. With chronic relapsers, however, there is frequently
an intense hopelessness and a cynical outlook on any possibility of
permanent sobriety. Upon arrival at Burning Tree Recovery Ranch, clients
often tell me they are here just so that when they die of this disease
their family will know they tried everything and will have peace. Based
on their life history, chronic relapsers are convinced they are beyond
repair.

Multiple treatment episodes, including psychiatric treatment, detox,
residential, outpatient, and halfway houses. This often includes relapse
just hours, days or weeks after getting out of treatment. Chronic
relapsers also have a significant history of using in treatment, getting
kicked out of treatment, and leaving treatment early.

Significant exposure, attendance and/or participation in 12-Step
programs. Chronic relapsers have a history of repeatedly working Steps
1, 2 and 3, but have never completed all 12. They have picked up
numerous "desire chips." They have attended countless meetings. They
even may have had sponsors. Unfortunately, they many times have just
enough experience with the 12-Step fellowship to think they know it
won't work for them. However, the majority of chronic relapsers have
never had a deep and meaningful experience through working all of the
Steps in the way they are intended.

Treatment savvy-have learned to navigate their way through the treatment
industry to meet their own agenda. Chronic relapsers often know how to
get around treatment center rules and to play the treatment center game.
They have been in and out of institutions and can easily figure out what
they need to do to graduate successfully and appease others. Chronic
relapsers also have a gift for splitting staff, influencing peers and
becoming a virus in a treatment community. Many times they have mastered
the art of working the therapists. They have learned to feign trauma,
trump therapeutic issues and play up their dual diagnosis symptoms.

A unique talent to exhaust the financial resources and emotional support
of loved ones. Chronic relapsers leave their loved ones depleted of
energy and emotional resources. They are often lovable and convincing,
which enhances their amazing ability to get their family members and
others to continue giving of their resources.

As with most addicts, a pervasive cluster of personality characteristics
are frequently exaggerated in the chronic relapser. We have found that
they are very charming, intelligent, manipulative, convincing,
deceitful, lovable, talented and passionate. These personality traits
often are what helped them survive through years of dangerous drug and
alcohol abuse and all that comes with that lifestyle. Chronic relapsers
have mastered the art of survival, in and out of treatment.

Axis II personality disorders or personality traits. Chronic relapsers
are many times diagnosed with or display significant symptoms of Axis II
personality disorders, especially borderline personality disorder,
anti-social personality disorder and narcissistic personality disorder.

Based on this description of the chronic relapser, it is clear that
there are common characteristics in the profile of these individuals.
They are predictable and easy to identify, if you know how to identify
them. It is important that treatment providers be educated on how to
identify a chronic relapser who needs specialized treatment. While they
are very treatable, it takes a very specific treatment strategy to work
effectively with them.

The biggest mistake I see in the treatment industry is repeated attempts
by unequipped treatment providers to treat chronic relapsers. This is a
specialized population that requires distinct treatment protocols.


Treatment strategies and techniques


Long-term length of stay. It is a well-established fact that long-term
treatment increases the chances of lasting sobriety. It is important to
define the term "long-term treatment," because too many, this would mean
90 days as opposed to the traditional 30. When I refer to long-term
treatment, I'm talking about a length of stay in excess of nine months.
In my experience, it can take a chronic relapser three to six months to
wake up out of the fog in which he/she has been living. Post-acute
withdrawal syndrome (PAWS) is very significant in chronic relapsers and
frequently interferes considerably with an individual's ability to
comprehend recovery principles in early sobriety. While many treatment
centers with this significant length of stay can require considerable
financial resources, there sometimes are financing options or
scholarships available.

Remove outside distractions. Chronic relapsers are masters at
distracting themselves and others from seeing the truth about them. It
is essential with this population to remove all things they use to
change the way they feel and to force them to sit in their own skin.
While all treatment centers must adhere to ethical guidelines and basic
client rights, it is well within the boundaries of a treatment center to
limit distractions through therapeutic contracts, clear-cut facility
rules and guidelines, and limited family contact.

Emphasize the mental and spiritual nature of the disease. Chronic
relapsers usually think they know what's wrong with them, but we have
discovered that despite their wealth of knowledge about addiction, they
have no idea what's actually wrong with them. It is essential that
chronic relapsers understand they have a disease of the mind, body and
spirit, and that the solution through the 12 Steps is spiritual in
nature.

Intervene on the family. The concept of treating the family in addition
to the client is by no means a new idea. However, with chronic
relapsers, we consistently see that the pathology of the family is worse
than that of the client. In most cases, the family has participated in
the progression of the illness in the chronic relapser through intense
enabling behaviors. Treatment for the family cannot just be a
suggestion; it must be non-negotiable. This includes Al-Anon involvement
at a minimum, and often requires intense counseling and even residential
treatment.

Use all leverage available. Family leverage is usually the most
significant in keeping a chronic relapser in long-term treatment.
Chronic relapsers must recognize in no uncertain terms that they will
not receive any emotional or financial support from their family if they
do not complete long-term treatment or remain sober. In addition, the
use of legal and custody leverage can be very powerful.

Stay one step ahead. It has been established that chronic relapsers are
treatment-savvy, tricky and highly manipulative. During treatment, it is
essential to stay one step ahead of an individual's con game at any
given time. Unfortunately, with this population, they don't have much
credibility for being honest, so it is important to investigate and
watch them closely. Don't take what they say at face value. Dive into
the minutia and the details. Don't give them an inch.

Work all 12 Steps with a sponsor. It is important that working the 12
Steps is not just a suggestion, but a requirement. Chronic relapsers
report that in most previous treatment, they talked and learned about
the Steps and were always encouraged to get involved in a 12-Step
program when treatment was complete. This is not enough for a chronic
relapser. These individuals must be held accountable to obtain a sponsor
and work all 12 Steps before they are released from treatment.

Relentless accountability. Treatment for the chronic relapser should
include a constant emphasis on accountability, responsibility and
consistency. It is essential that there be rules, limits, boundaries and
consequences with this population. At Burning Tree we often tell our
clients that their actions speak so loud we can't hear a word they say.
Chronic relapsers have had a lifetime of taking little responsibility
for their actions and displaying no accountability for their behavior.
This must change and the treatment provider must lead the way.

Working with the chronic relapse population by nature entails dealing
with individuals who display significant resistance to treatment. While
treatment requires constantly challenging this resistance, noncompliant
behavior that persists beyond a reasonable amount of time or begins to
interfere with others' treatment can't be tolerated. Clients must
occasionally be discharged as noncompliant, which reinforces to the
chronic relapser that he/she can no longer successfully live on self
will. If the family has established its own personal recovery, those who
are therapeutically discharged will often find the removal of all
enabling systems very difficult and will often return to treatment to
finish out with a new willingness.

Real-time behavior intervention. Chronic relapsers must be intervened on
consistently. Confronting their misbehavior 24 hours after the fact is
ineffective-it must be confronted in the moment and they must be given
no wiggle room. Chronic relapsers have to develop an openness to this
level of accountability to prepare them for a life of sobriety and
honesty.

High levels of structure from wake-up to bedtime. Treating a population
of chronic relapsers always involves little down time and high
structure. The client's full-time job is learning a new way to do life
that will lead to lasting sobriety. This requires punctuality, time
management and prioritization. Clients' willingness and discipline in
these areas speaks volumes about where they are in their recovery
process.

Refuse to engage in word games. Chronic relapsers can be very
intelligent and good with words. Family members are often baffled over
how the chronic relapser can disarm them during arguments by using their
words as a weapon. It is important for treatment providers to box in
chronic relapsers in order to disable their ability to manipulate with
words. Set standards that do not allow them to use words such as
"kinda," "sorta," "maybe," "partially." Make them answer questions with
a simple "yes" or "no." Identify and confront them when they fail to
answer a question and divert to a different subject.

Focus more on action and less on feelings. This population has had years
of counseling, talk therapy, experiential therapy and feelings work.
Unfortunately, for the vast majority of chronic relapsers, it hasn't
helped them find lasting sobriety. While therapy is a necessary
component of any treatment for a chronic relapser, the focus must be on
the individual's actions. A client's actions do not lie.

Deflation of the ego. Chronic relapsers are an entitled population. This
is true whether they come from a privileged background or poverty. The
last thing this population needs is pampering, amenities, coddling or
material comforts. At Burning Tree, our clients do not have a chef or
any housekeepers. They cook all their own meals, do their own shopping,
mow their own lawn, clean their own living space, and do their own
laundry. Hard work is important for this population. More importantly,
enabling in the form of others doing for them what they can do
themselves can be very detrimental.

Speak the truth. At Burning Tree Recovery Ranch we tell clients that we
care more about their life than we do about hurting their feelings. Most
chronic relapsers have held people in their life emotionally hostage
through threats to relapse, actually relapsing, threats to harm
themselves, harming themselves, blaming, and creating fear. This
emotional terrorism keeps loved ones in a position of walking on
eggshells around the chronic relapser. It is essential that this
perceived power be removed from the chronic relapser. Treatment
providers must be willing to show up and tell these clients the tough
truth.

Creating an environment where it is possible to implement these
treatment techniques can be challenging. It takes a very specialized
program to treat chronic relapsers. Properly identifying chronic
relapsers and getting them into a long-term program that is designed
specifically for this population is critical to breaking the cycle of
addiction.

Take the Continuing Education Credits Quiz associated with this article
on page 35.

Heidi Voet Smith, LPC, is Clinical Director for Burning Tree Recovery
Ranch in Kaufman, Texas (www.burningtree.com), specializing in working
with addicts with a history of chronic relapse. Her e-mail address is 
hvsmith at burningtree.com.

 

Addiction Professional 2011 September-October;9(5):10-19

 

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