Aftercare planning: Can the client reasonably choose?
As a provider of transitional-living services for young adult men in early recovery from addiction, I have noticed a concerning trend in our industry. It seems that families and treatment centers are leaving the decision for aftercare plans in the hands of the client. It is a theme that has been surfacing for some time and puts the onus for type and length of aftercare back on the clients themselves, leaving the decision purely on them.
In theory, I understand that families and treatment centers want individuals to “buy into” their own recovery, be “a stakeholder” in the decision and take “ownership” over their treatment process. However, is this always in their best interest? I question whether it is truly a desire to support autonomy, versus a statement driven by intense fear of the young person's reaction to being unhappy.
I continue to be amazed at an addicted individual’s ability to hold a family hostage purely with the threat of one's feelings, reactions and behavior. Families may take a hard line for primary treatment, but then loosen up when it comes to aftercare plans. I have seen this become a deadly choice all too many times.
Clients typically will choose an aftercare program with a shorter length of stay, more freedom and less accountability. I believe we all would, if we faced that decision. In May 2007, Nora Volkov, MD, director of the National Institute on Drug Abuse (NIDA), presented her epic talk “The Neurobiology of Free Will” at the American Psychiatric Association (APA) conference. The talk solidified the research pointing toward addiction as a true brain disease, as she presented a complex picture of how drugs compromise numerous regions of the brain in ways that place continued substance abuse as a priority over users' own best interest and the best interest of others.
All too often, the addict or alcoholic sprints from treatment to focus on acquisition of a relationship, the latest technology, a car, an apartment and a job, while recovery itself falls by the wayside. In the short term, the individual might appear happier while these “wants” produce immediate comfort, but changing the outside circumstances doesn’t treat the inside, and relapse offers a painful reminder of that.
After a relapse, we often conclude, “Perhaps he just didn’t want it.” Well, perhaps he did. Perhaps he simply wasn’t ready for so much freedom, wasn’t fully transformed through the recovery process, and saw things get in the way as immediate gratification took priority. All of this resulted from the logic during aftercare planning that this individual “is an adult and should make his own choices.”
It has been established in research that coerced treatment is just as effective as voluntary treatment. NIDA has reported that most studies have found that outcomes for those legally pressured to enter treatment are at least as good as outcomes for those who entered treatment without such pressure. I believe that if family support systems provided the same level of “pressure,” outcomes would be similar.
I believe in unconditional positive regard for all clients and in an individual’s right to be a participant in treatment, but I also believe in the power of addiction and its overwhelming ability to warp the thinking of an individual still suffering from the sickness. Addiction is a liar. It tells us we are ready when we are not. It tells us everyone is overreacting when they aren’t. It tells us if we just get our life back in order things will be OK, when they won’t. I refuse to pretend that our clients' decision-making is not affected by their addiction.
Many would say that when coerced into a program, an individual does not obtain surrendered and sustainable recovery, but instead superficial compliance. In my experience, it is rare to get superficial compliance for much longer than 30 days. Individuals simply cannot hold their breath for much longer than that. I’d prefer to engage the resistance and work with it.
In his paper “Toward a Philosophy of Choice: A New Era of Addiction Treatment,” William L. White admits, “I suspect mismatches in the degree of choice allowed in the treatment process (both ill-timed episodes of too much and too little choice) contribute to high rates of treatment non-completion via clients leaving against staff advice and clients being administratively discharged.”
When a team of professionals unites with a family to make healthy decisions for aftercare plans, I have seen amazing results. Clients may not like the decision, but honestly, it doesn’t matter if they like it. It matters that they get well. The best-case scenario occurs when individuals surrender to the reality that the best choice they can make in early recovery is to make the conscious choice not to choose, but rather to rely on trusted professionals, family and friends.
Qualities of good aftercare
Aftercare planning can and should be very individualized. However, there are key components that I believe are consistent in all good transitional-living and aftercare programs. Here are some questions to ask:
1. How many full-time staff members does the program have? Many sober-living homes have only an owner and a live-in house manager with very little sobriety time. Depending on the specific needs of the client, this often is not enough oversight for a client with a complex set of circumstances and a history of chronic relapse. Without enough staff, an individual will slip through the cracks. Preferably, there are numerous full-time staff who are deeply invested in the success of each resident.
2. What is the nighttime supervision? When a sober-living program states that it has “24-hour supervision,” you may want to dig deeper. If the staff is asleep on-site, that is usually when troublesome behavior happens among residents. It is impossible for a house manager who is asleep to provide monitoring and supervision.
Preferably, there is awake staff available to monitor the overnight period and ensure the safety of all residents.
3. Do they have a required daily schedule that must be followed?Residents at sober homes often lack discipline—they lie around, sleep late, play video games all night, and can be generally unproductive. Also, residents may be required to leave the house during certain hours of the day with no accountability and no direction. An environment with little structure and accountability can be a setup for failure and relapse. Preferably, all residents have a firm schedule that they are accountable to following, with productive goals and milestones throughout the day.
4. Exactly how does the program help with career and educational goals and life skills? Most sober-living houses promote their services of helping residents learn life skills, find a job and create a new life. But it is important to understand how they do this. What is the curriculum and what kind of support is provided, and for how many hours each week? Are clients left on their own to walk around a new city and find a job, placing them in a vulnerable position with little foundation in sobriety? Preferably, a program has a firm life skills curriculum and support services in place with case management, mentorship and accountability.
5. Are residents allowed electronics? It is important to understand if a transitional-living program slowly reintegrates clients back into real-world access. This is often the biggest sticking point with residents—they want their access to social media, text messages and their network of friends. This is obviously inevitable, but it is not necessary or helpful when the priority should be building a new sober life. Residents desperately want to stay “connected,” but electronics usually do the exact opposite, keeping them disconnected from building a sober support network, connecting with their Higher Power and staying focused on recovery.
6. What kind of transportation is provided? Most sober-living homes restrict access to a car, which is a very valuable boundary. However, residents often are left to navigate a new city, placing them in a vulnerable position to miss important appointments and meetings. In early recovery, being consistent with meeting attendance, counseling appointments, psychiatrist appointments and prescription pickup are of the utmost importance. Preferably, a transitional-living program has support in place to help residents make these tasks a priority.
7. Are clinical services and clinical support available? In early recovery, it is imperative that individuals continue seeking treatment through outpatient clinical services. In the first few months of sobriety, individuals have dual diagnoses that are still regulating, trauma that is just coming to the surface, relationship issues that are causing chaos, and an incredible amount of fear, guilt and shame. Without clinical support in the way of services such as individual and group counseling, Eye Movement Desensitization and Reprocessing (EMDR), and meeting with a psychiatrist regularly, an individual in early recovery can be very vulnerable to relapse.
8. Is the program firm in its philosophy? I believe it is important for addiction programs in general, but transitional-living programs specifically, to have firm beliefs and boundaries about the recovery process. Whether the program is 12-Step or religiously based, it should have clear guidelines for what is required in the program, and milestones to measure success. All too often, I run into programs that allow clients to “individualize their treatment” to the point where there is no treatment—the client is allowed to call the shots, with no accountability, no spirituality, and no boundaries.
Heidi Voet Smith is a Licensed Professional Counselor and Supervisor who, with her husband Michael, founded Chapter House Sober Living and Counseling Center in Dallas, a transitional-living program for young-adult men. She serves as Chapter House's clinical director. Jeff Gould also contributed to this article; he is a humorist, writer and crisis interventionist with 15 years of experience working in the behavioral health field.