It Takes A Family: A Cooperative Approach to Lasting Sobriety
By Debra Jay
We have a problem.
Fifty to 90 percent of alcoholics and addicts relapse in the first year after treatment. In the face of such grim figures, it’s easy to toss around blame. Treatment doesn’t work. The addict isn’t doing what she should. Doctors are the new drug pushers. But the truth lies elsewhere for the
most part, and requires a new conversation.
Relapse is caused by underestimating what it takes to stay sober. Addicts, their families, and society commonly minimize what is required for successful recovery. Addicts can’t simply think their way out of addiction. Recovery requires action. It’s much more than leaving the drug behind, whether that drug is alcohol, cocaine, marijuana, heroin, methamphetamine, pain medications, or tranquilizers. Recovery is about changing behaviors, which leads to changes in thinking. It’s about honesty and willingness and letting go of resentments. It’s about taking a fearless look at one’s self and the wrongs of the past. It’s about cleaning house and making amends.
Recovery is about more than abstinence; it’s about becoming the kind of person who can engage in healthy relationships. Abstinent without recovery, the addicted person is haunted by the past, suffers in the present, and can’t see a promising future. The control centers in the brain are being depleted by the constant internal battle not to pick up a drink or a drug. Relationships with family are frayed and getting no better. For these addicts, relapse is usually just a matter of time.
An old adage says it best: “When a heavy drinker stops drinking, he feels better. When an alcoholic stops drinking, he feels worse.” For alcoholics and addicts to begin enjoying life again, they need to work a rigorous Twelve Step program of recovery in groups such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). These programs work because they treat the chronic nature of addiction that affects the mind, body, and spirit. There is no cure, only a daily reprieve that requires ongoing management. If we don’t understand this basic tenet of success, we don’t understand recovery.
When we believe treatment centers are the heart of recovery, we base our hopes and dreams on a flawed assumption. Treatment isn’t recovery, and clinical teams don’t know who will stay sober and who won’t. Stellar patients drink on the flight home, and seemingly hopeless cases never drink again. Treatment staffs know what works, but no one knows who will follow directions and do what it takes to stay sober.
Recovery doesn’t officially begin until treatment ends. It isn’t dished out by doctors or teased out by therapists. It happens in a community and not just any community. It requires working a Twelve Step recovery program with other alcoholics and addicts. Recovery requires broad changes in how addicts live their lives, the kind of changes that would be tough work for anyone. They are attempting it with a brain so compromised by addiction that their brain scans look like Swiss cheese. With decision-making abilities impaired and emotions turbulent, it’s no wonder so many don’t get very far before they crumble and relapse.
The purpose of treatment is specific. It is designed to attend to the acute stage of this chronic illness. Involvement with patients is relatively short. A team of professionals administer to the most intense and severe symptoms, most notably the physical and emotional discomfort that comes with early abstinence. And many do an excellent job of it. But the score card we use to rate the success or failure of these facilities erroneously holds them responsible for patients’ sobriety once they return home. Since addiction is a chronic disease, it must be managed by working a daily Twelve Step program. Treatment centers can only prepare patients to follow through with their ongoing recovery but can’t do it for them. If addicts don’t follow the directions for ongoing recovery, they are at high risk for relapse.
While not making direct promises of keeping people sober long-term, with some notable exceptions, treatment centers do so implicitly. Instead, professionals need to be very straightforward about what they can do, why it is important, and what they can’t do.
This is exceedingly important because today we have so many treatment centers popping up across the country, trying out new strategies and protocols that will differentiate them from the pack but that aren’t necessarily effective. This makes it difficult for families to evaluate treatment options. It’s difficult to be smart consumers in a confusing arena.
The problem begins with the rubrics we’re using—our scoring guide to evaluate the quality of treatment—which are flawed. Treatment cannot be responsible for recovery outside the treatment program. It can only be held responsible for its effectiveness at:
- Medically detoxing and stabilizing patients, thoroughly assessing their needs, and setting treatment goals
- Working with patients to break through denial at the deepest possible level, in a respectful and dignified manner, so they accept that they have a chronic disease that requires lifelong abstinence
- Providing patients a recovery management plan that includes relapse prevention strategies and a clear understanding of how to work a Twelve Step recovery program when returning home (encouraging the patient to go to AA or NA meetings while in treatment and connecting the patient to a recovering person in his home area help accomplish this goal)
- Inviting the family to attend the family program, and encouraging the children to attend a children’s program if one is available
- Developing aftercare recommendations designed to give an appropriate level of support that will increase the likelihood that patients will engage in recovery once they leave treatment
- Engaging the family in the entire process, as appropriate.
There is also much talk about evidence-based treatment, but even though intentions are good, there are problems. Evidence-based doesn’t necessarily mean the research is flawless, nor does it mean it is measuring the same outcome we should all be aiming for: lasting sobriety.
Results depend on the quality of the research, the validity of the testing, replication over time by impartial researchers, and reviews by other researchers. Research bias—particularly the bias of what is actually published (mainly the positive results)—can lead to “proving” something is true when it is not true. Instead, we should be talking about “levels of evidence” and “quality of evidence.”
According to Eric Topol, MD, cardiologist, geneticist, and researcher from the Cleveland Clinic, in his book The Creative Destruction of Medicine, “Consumers, unfortunately, are typically getting data from small, observational studies, published in obscure journals or not at all, in which there is no real control group or no randomization, and shaky end points.” He goes on to say that even very large-scale observational studies have produced faulty results, misleading the public more than once. Professionals are misled, too.
Dr. Topol has coined the word litter-ature, denoting that too much of the research is “littered with misleading and false-positive findings.” We must be smart consumers of research, he says. “I don’t want to be excessively negative, but the right assumption in reviewing any new data presented to consumers is to question it . . . consider the new finding null and void unless you are thoroughly convinced that the evidence is compelling.” He is speaking of medical science, but results in the field of addiction and behavioral health are even more tenuous.
Misconceptions about treatment, leading to false expectations, coupled with the frustration of relapse, have families throwing up their hands and proclaiming, “Enough! Treatment doesn’t work!” Once they reach this verdict, hopelessness can settle in, and the only question left is, “Now what?”
But what if I told you there was a group of addicted people who almost never relapse in the years following treatment? As a matter of fact, 78 percent never have a single relapse. Less than 15 percent have one relapse but not a second. And those with more than one relapse? Awhopping 7 percent. Not only that, but these folks are some of the most difficult addicts to treat. When I worked in inpatient treatment, having them assigned to our caseload would elicit groans of despair. “They’re the worst patients!” because we knew our work just doubled.
But these patients are getting something other addicted loved ones aren’t: a team who work with them for five years after treatment to make sure they build a solid program of recovery and make the prerequisite changes that lead to lasting sobriety. Because when alcoholics and addicts are left to their own devices—in spite of the universal cry that they can do it on their own—the odds are they’ll be drinking and drugging again.
Author Stephen King, in his column for Entertainment Weekly, writes about just this point.
Managing good sobriety without much help . . . is a trick very few druggies and alcoholics can manage. I know, because I’m both. Substance abusers lie about everything and usually do an awesome job of it. I once knew a cokehead who convinced his girlfriend the smell of freebase was mold in the plastic shower curtain of their apartment’s bathroom. She believed him, he said, for five years (although he was probably lying about that, it was probably only three). . . . Go to one of those church-basement meetings where they drink coffee and talk about the Twelve Steps and you can hear similar stories on any night, and that’s why the founders of this group emphasized complete honesty—what happened, what changed, what it’s like now. . . . If my own career as a drunk both active and sober has convinced me of anything, it’s convinced me of this: Addictive personalities do not prosper on their own. Without unvarnished, tough-love, truth-telling from their own kind—the voices that say, “You’re lying about that,Freckles”—the addict has a tendency to fall back to his old ways.
The problem is, of course, that most alcoholics and addicts coming out of treatment don’t want to work a program of recovery that requires taking action. They’re convinced they have changed with surprisingly little effort and in a remarkably short amount of time, and they often convince their poor gullible families of the same. These alcoholics and addicts think they have a better idea, which usually entails staying sober on their own with an easier, softer approach, one that eventually lands them back in the liquor store or crack house or doctor’s office looking for a scrip.
This lack of compliance is repeatedly used by professionals and researchers as the reason AA or other Twelve Step programs don’t work. Confusing an addict’s compliance with a program’s effectiveness is faulty analysis, either due to a lack of critical thinking or a degree of bias that leads to foregone conclusions. More accurately, the problem is one of compliance. It isn’t that Twelve Step programs don’t work—it is that alcoholics and addicts, for a complex set of reasons, have difficulty adhering to anything in a consistent manner—for reasons that are both purely human and that are central to the disease of addiction. Consider the struggles diabetics have trying to comply with their recovery programs—and they do not have to contend with the cognitive impairment we see in addicts. Research shows that among patients who only needed to take a medication to treat their illness, only 50 percent complied. What it takes to recover from addiction is in another stratosphere from swallowing a pill.
But what if we, as families, could initiate a program with our loved ones that models the programs used by the recovery winners mentioned above—those people who almost never relapse? What if we could provide the missing element that makes it much tougher to relapse? Once we appropriately define the staff in treatment centers as the “first responders,” not as providers of a stand-alone solution that does all the work for us, our expectations of treatment change. No doubt, treatment has a vital job to do, but it’s not the only job to be done. Treatment centers can keep our alcoholics and addicts only so long, and then they come back home to us. This is when it takes all of us bonding together in recovery if we’re to take our place among the winners. It most definitely
takes a family.
Families and close friends have a tremendous amount of influence in an addict’s life but usually don’t know it. Too often, families not only don’t understand their power, they often believe they are powerless. They often feel mistreated, disregarded, even hated.
The very people an alcoholic or addict needs most are the people he often fights against. He tries to appease family, only to break the promises he makes to them. Or he ignores those closest to him, pretending he simply doesn’t care. The addiction not only punishes the people the addict cares about most, but it abuses him, too. He breaks promises to himself. He pretends none of the pain matters. And he begins losing everything he holds dear, yet he can’t stop this downward spiral. He is typically filled with shame as he strikes out in anger. He doesn’t understand what is happening inside himself. That is what it’s like to live under the tyranny of addiction. However, a rigorous recovery program can reverse the insanity of this disease, making things better one day at a time.
Most books on recovery from addiction focus either on the addict or the family. While most alcoholics and addicts coming out of treatment have a recovery plan, families are often left to figure things out for themselves. In It Takes a Family, Debra Jay takes a fresh approach to the recovery process by making family members and friends part of the recovery team, beginning in the early stages of sobriety.
In straightforward, compassionate language, she outlines a structured model that shows family members both how to take personal responsibility and to build a circle of support to meet the obstacles common to the first year of recovery. Together, family members address the challenges of enabling, denial, and pain while developing their communication skills through practical, easy-to-follow strategies and exercises designed to create transparency and accountability.