Guide to Navigating the Treatment System
One Size Does Not Fit All - Finding Treatment
When it comes to getting help and sustaining change, we know people need different types of support, at different stages of the change process including inpatient and outpatient treatment, self-help meetings, treatment for co-occurring issues, family therapy, medication, talking to a spiritual advisor or mentor, starting healthy diet and exercise routines, or picking up a new hobby. Or a combination of all of these things!
The treatment landscape is complex and what a person needs depends on a variety of things including: the substance(s) being used (how much, how long), the underlying reasons for using, medical and mental health issues, developmental stage of life, the environment around them. Access to quality treatment and insurance/financial resources are additional complexities. The reality is, each person struggling with a substance problem is different. Each family (bio or chosen) who cares about them is different. Some people need to be in their home environment in order to make changes, while others need to remove themselves completely. It’s crucial that each person and family dealing with substance problems thinks through the variables that are unique to them.
The process of deciding what treatment to try can be difficult on a good day, and even more so when you are scared or in crisis. If you are someone who is looking for treatment for yourself or a loved one, we encourage you to take as much time as you can to interview several treatment providers and arm yourself with a list of questions that will help you compare and contrast them before you make your final decision.
While it may be tempting to search for “best rehabs,” we recommend against it because the internet is full of 1-800 call services that appear to be linking you to someone who can help you find the best options. The thing they don’t tell you is that they are more than likely paid by specific programs to make referrals, and their suggestion of the best place for you will not be based on anything other than the out-of-pocket expense you can afford or your insurance benefits.
If you can, try to arrange a face-to-face professional assessment since people turn to substances for a variety of reasons (Behaviors Make Sense). Be sure to ask about the qualifications and approach of the person doing the assessment (see additional comments below) since they have a huge impact on the recommendations that they will make. Once you get feedback, you can move on to exploring the following questions. If you can’t get a good assessment, then just proceed to ask these questions of any program you are considering.
Here is a short primer for what to look for in a treatment program. The following questions will help you find support that matches your specific needs.
Questions to Ask
What is your Treatment Philosophy?
Different treatment programs have different philosophies about how to help someone with their substance use problems. Some places adhere closely to the traditional 12-step approach, while others take a cognitive-behavioral or harm reduction approach. As you review program websites, you may notice that lots of programs say they do – everything.
While a website may be a good way to start the process of finding a treatment program, calling a program directly is much more informative. How you are treated on the front end and the answers they give to your questions can be a good indicator of what you can expect in treatment. In addition to asking about treatment philosophy, it’s a good idea to ask specifically:
- How do they determine which treatment modality will be provided and how it is offered (i.e., individual sessions, group sessions, or lectures).
- How many individual sessions with a primary therapist are offered and what the focus of those sessions is (e.g., skills development, aftercare planning etc).
- If there are groups, ask about the content, frequency and number of people in each group.
- Is there a medical team and how are they involved? Can you see an MD for a medication consult? Do they have restrictions on what medications can be used while being in the program? If yes, what are the off limit medications and why.
- What kind of training, support and supervision is provided to the treatment team?
If the person taking your call says something that you don’t understand or is too vague in their explanations, ask them to clarify. If they can’t do it or don’t do it well enough for you, that might be a sign about how happy you will be with the treatment program overall. Also, be on alert for black and white statements that make you feel scared or pushed into a corner, as they are a true sign of the program philosophy.
Who provides the actual treatment? What are their credentials? And how are they supervised and trained?
Treatment programs differ widely in who on staff has actual day-to-day therapeutic contact with clients. As you interview programs, ask the level of training of the providers running groups and providing individual therapy. Many programs are staffed largely by counselor level providers, and some states require only a high school degree in order to be eligible for the certification. Many people with this level of training are talented and have other degrees or specialties that are helpful but others are ill-equipped to treat mental health issues. If you are considering a program for co-occurring mental health issues, look for supervisory staff with doctoral or medical degrees and that treatment is provided by a masters-level clinician or above.
What are Co-Occurring Disorders?
While prevalence rates depend on several factors, including gender, age, and type of substances used, studies find that 50% of people with substance problems have other mental health issues, including depression, anxiety and personality disorders (Flynn & Brown, 2008). A large study of the prevalence of co-occurring disorders found that approximately 20% of all people with a current substance use disorder had at least one non-substance-induced mood disorder like depression, and 18% had at least one non-substance-induced anxiety disorder (Grant et al., 2004).
There are also very high rates of Post-Traumatic Stress Disorder (PTSD) and trauma in substance abusing populations (and vice-versa): 29% to 79% of those with PTSD have substance use disorder, while 30 to 60% of substance abusing clients have PTSD (Cohen and Hien, 2012, McCauley et al, 2012). This matters because people often turn to substances to self-medicate underlying mental health problems.
Remember, Behaviors Make Sense. In the short term, alcohol and cocaine can seem to alleviate depression or social anxiety. Opiates can give people a sense of calm and reduce pain. Substances have effects that people like for some reason (different people, different reasons) and those underlying reasons need to be addressed if you are going to help someone rely less on substances.
Awareness of the importance of co-treating co-occurring disorders is growing, but there continues to be a wide range of provider skill in using evidence based treatments to address them. If you are looking for treatment for yourself or a loved one, you should ask specifically about the training and the ongoing supervision of the clinical staff when it comes to treating co-occurring disorders.
What are your feelings about medications and how often is there access to a psychiatrist?
Just as programs have different treatment philosophies, they can have different philosophies about medication. Many programs are“abstinence only,” which means they hold the belief that the job of a treatment program is to get the client off of all substances, including prescribed medications that are sometimes associated with misuse (e.g., stimulants). Unfortunately, these programs are also often against the use of very effective medication-assisted therapies such as opioid replacement medications (e.g., methadone and Suboxone) and Naltrexone. While many of these programs have had to change their position due to public pressure associated with the rate of overdose from opioids, their ambivalence about these medications often causes them to be less supportive than they should be of many clients who may need to be on long term maintenance. At the other end of the spectrum are programs that are poorly managed and unscrupulous clinics that distribute buprenorphine without additional behavioral supports or family involvement. Beware of programs offering medication only.
Medication-assisted treatment (MAT) is an evidence-based approach that combines the use of medications with counseling and behavioral strategies. Like most if not all medications, those appropriate for treating substance use disorders have their downsides and side effects, but the evidence supporting them as effective agents against relapse and overdose death is robust. The data suggest as many as 70% of people detoxed completely off opioids relapse within the first one to two months unless treated with these medications (Chalana, H., Sachdeva, J. K., Kundal, T., Malhari, A. S., & Choudhary, R. (2015). Other research has shown that these medications double the rates of abstinence from opioids when compared to placebo or no medication (Connery, 2015).
If you or your loved one is interested in MAT options, ask the treatment program about their stance on medications. Specifically inquire about whether or not they are willing to maintain clients on opioid replacement medications or whether they discharge clients on Vivitrol (for opiates or alcohol) or Antabuse (for alcohol). Again, if the explanation isn’t satisfying to you, or seems to go against what you’re reading here or elsewhere, that’s an important sign that this program might not be right for you. Also ask how often the psychiatrist will see you or your loved one, as frequency is the only way medications can be well monitored and tailored individually to your needs.
If this program isn’t right for me/my loved one, what is your refund policy?
Unfortunately, even when you have done all your homework and planned everything out as much as possible, sometimes the “fit” just isn’t right and you won’t know that until you participate in the program. Many programs require payment up front, and it is important to know how they will handle it if you decide the program isn’t a good match for you. Many places do not offer partial refunds, but some do and will work with you if you decide to end the treatment relationship. It’s important for you to know those details, as it can lead to an extended battle for your money (and adding another battle is not really consistent with self-care!).
How do they help you develop an aftercare plan (if inpatient) or ongoing plan (if outpatient), and how do they work with treatment providers you already may have in place?
As you try to identify an inpatient program, look for ones that will help you build a very clear and supportive aftercare program that is developed in collaboration with you, and some follow-up for a period of time to make sure you are connecting to the supports in your community. You also want to know how they are going to collaborate with any providers you have already been working with. Will your inpatient therapist talk directly to your outpatient therapist or psychiatrist, or is it just the admissions team who will call them? If it is the latter, be advised that information can get lost in translation and advocate that your team talk directly to each other, and frequently. You would be surprised how many treatment providers never pick up the phone to speak to another professional.
This primer is just the tip of the iceberg of what to look for in a treatment program. For more information about what to look for, look to Ann Fletcher’s book Inside Rehab to learn more about what happens in rehabs and different programs, when rehab is the best choice (and when it’s actually not the ideal treatment setting), as well as more questions to ask as you make your decision.
Types of Treatment: Glossary
There are lots of different types of help available for someone who is struggling, and it can be a bit confusing to understand the differences. Below we have mapped each level of care.
Below is a primer summarizing different types of support that might be helpful to you or a loved one when trying to make changes in substance use.
Self-Help Meetings: Self-help meetings are free and run by non-professionals. They include AA, NA, SMART Recovery, Refuge Recovery, Recovery Dharma and Women for Sobriety to name a few. All of these organizations have different philosophies about how to approach the problem of addiction and behavior change and many have in person and virtual options. We recommend trying multiple options so that you can find one that is closely aligned with your values and goals.
Individual/Group Therapy: While many therapists work with substance users, it can be important to ask about the treatment “orientation” or the level of training they have in the best evidence-based practices for substance use disorders. The best treatment approaches are often more skills based, with an emphasis on building an understanding of what kinds of things in your environment trigger you, how to handle triggers and cravings in the moment, and a focus on building skills to help prevent a relapse to old behaviors.
Don’t be afraid to ask treatment providers you are considering working with a lot of questions! It’s worth doing your due diligence as providers have a range of orientations, fees, level of experience and training.
Medication Support: Oftentimes it is crucially important to get medication support when you are trying to address a substance use problem. Psychiatrists have a range of experiences and training so it is important to look for those with specific training in addiction as they have a deeper understanding of substance use, treatment modalities, and how to prescribe medications to someone with a substance history. It also helps to find a psychiatrist who will collaborate with the rest of your “team” (therapist, sober coach, group program etc) and communicate about any changes in medication etc..
Intensive Outpatient Programs (IOP): These are a collection of group and individual treatments that create a whole treatment program that can be done in an outpatient setting. Ranging from 3 – 6 hours daily, anywhere from 3 – 7 days per week, IOPs will often include some skills building, some 12-step “step work” (depending on the orientation of the practice providing the treatment), some individual meetings, and more. They range in quality and price, and in their focus on skills building vs. step work. For a more rich experience, try and find a program that has specific skills building groups, has individual treatment weekly with a licensed therapist, and will work closely with addiction psychiatrists.
Sober Coaches/Companions: Sober coaches work are “out in the world” with you. They can be with you in your home, office, when traveling etc and can help you deal with the challenges that come with making significant life changes. For example, they can help someone who is depressed or socially anxious to get up and get to appointments and help navigate potentially risky situations (like social events) without using.
While these supports can be really helpful, the sober coach field is not a “well monitored” one. Sober coaches do not need a license to practice and while there are starting to be certification programs, most coaches do not have any specific training other than being “in recovery” themselves. It is important to ask any coach you are considering about their credentials or training and get recommendations for treatment providers. Additionally, their fees vary (e.g., by the day, by the hour) and are not typically reimbursable by insurance so the financial aspects of this type of support need to be considered.
Sober Living: Sober livings are supervised living situations where people live in a house with other people who are all working to abstain from substances. They can range in quality, both quality of living and quality of support, and can range greatly in price. There is usually very little or no “treatment” that goes on in-house, although many will provide a sober coach (often at an additional cost) and will require people to attend daily 12-step meetings.
Inpatient Rehab: This is the highest level of care, and in most cases should be saved until after a person has tried some of the lower-level outpatient treatment options listed above. Similar to Intensive Outpatient Programs, these rehabs will range in quality and price, orientation (12-step versus Evidence Based approaches) and in how much contact you will have with a highly trained individual therapist. For an excellent book on all things rehab (including what to look for and what questions you should be asking), we recommend Anne Fletcher’s Inside Rehab (attach link). It is a non-biased review of the rehab world and gives consumers all the information they need to find the place that’s right for them.
There has been a major shift recently towards evidence based practices and rehabs have started to move towards having more evidence based treatment options available to clients. That said, it is important for clients to ask about how those treatments are presented, who runs those groups, where they were trained, etc. Many more rehabs are calling themselves “evidence-based” than are necessarily practicing it! So ask lots of questions!
Types of Treatment Approaches
If in reading through our website you find that you are interested in finding an approach that aligns with our work, we recommend that you explore therapists who have training in some of the following areas. These types of approaches are often referred to as Evidence Based (or EBT) approaches to treating substance use and other compulsive behaviors.
The most effective treatment strategies and settings focus on all areas of a person’s life, not just on helping them decide to use or not. They need new hobbies and interests to compete with using; new friends that share these interests and are supportive of change; and new ways of managing emotions and regulating the body (appetite, sleep, energy). People need understanding and support as they identify their values and sense of purpose, and learn to live accordingly. Relationships that may have been damaged will need repairs. In many cases people fall behind in school or at their jobs, and they will need to catch up on lost time. This is all a lot of work, for the person with the problem and everyone trying to help them. The following therapy approaches are well-suited to address all of these issues.
Cognitive Behavioral Therapy (CBT)
This approach encompasses a range of protocols, but as the name implies, they share the goal of helping people learn new ways of thinking and new behaviors. Treatment includes training in communication skills (both positive communication and assertiveness skills), relapse prevention skills (including drink refusal skills, dealing with high risk situations, problem solving skills, avoidance procedures and relaxation and stress reduction strategies), and cognitive strategies for dealing with negative self-talk, rumination, planning for the future, and thoughts about substance use. CBT can include practical matters such as job seeking, money management, planning, and relationship management. It’s a pragmatic therapy, with daily and weekly goal setting, ongoing “how’s it going?” assessments, homework assignments between appointments to practice new skills in “real life,” and a focus on problem solving. Note to participants: homework is critical to success.
Dialectical Behavioral Therapy (DBT)
Dialectical Behavior Therapy (DBT), is a research-proven approach to managing emotions and impulses. First developed in the late 1970s by Marsha Linehan, a psychologist at the University of Washington working primarily with patients struggling with Borderline Personality Disorder, DBT combines the skills of Cognitive Behavioral Therapy (CBT) with a secular, psychological adaptation of Buddhist wisdom and practice. It’s a potent meeting of East and West that has stood the test of western scientific standards.
Motivational Interviewing (MI)
MI is a collaborative conversational and counseling style for strengthening a person’s own motivation and commitment to change. It has been particularly helpful in highlighting the presence of ambivalence in the change process and providing meaningful ways to interact with individuals who are struggling with their motivation to make changes in their substance use and other health related behaviors. MI pays particular attention to the relational stance between individuals (e.g. building a respectful and empathetic environment) and offers guidance on how to build and navigate collaborative conversations that help individuals resolve their ambivalence.
Acceptance and Commitment Therapy (ACT)
ACT is a treatment approach that focuses on helping individuals establish a set of processes that can help foster greater psychological flexibility and well being. Developing psychological flexibility can be facilitated by mindfulness strategies, commitment and behavior-change strategies, as well adopting an openness to the emotional and psychological experiences that arise when moving towards one’s chosen values. Numerous investigations have supported that these methods are beneficial for a broad range of individuals and positive psychological goals across the areas of mental and behavioral health, and social wellness areas.
Invitation to Change Approach (ITC)
The Invitation to Change Approach® draws from CRAFT (Community Reinforcement and Family Therapy), MI (Motivational Interviewing), and ACT (Acceptance and Commitment Therapy) to empower loved ones with a new understanding of substance use. With a skills-oriented, compassionate outlook, the Invitation to Change Approach® works to reduce shame and stigma, while providing tools to foster growth and promote change.
Community Reinforcement and Family Training (CRAFT)
CRAFT is a behavioral and motivational treatment for families based on the empirically supported Community Reinforcement Approach (CRA). It has been studied extensively in randomized controlled trials among a variety of populations (e.g., different socio-economic groups, racial/ethnic groups, types of substance used) and has been found to be more effective for helping loved ones engage in treatment compared to other formal intervention programs and avenues of family support (like Al-Anon).
CRAFT has two goals: engaging the substance user in treatment through behavioral training for the family members, and enhancing family member self-care. It helps family members create an environment where abstinence/change behaviors are positively and incrementally reinforced and recognizes the family as powerful collaborators in effecting change instead of encouraging them to detach or use confrontation to impact their loved one.
Suggesting Treatment to your Loved One
Treatment can be one important part of how someone makes changes in their behavior. But we’re surrounded by messages in our culture that imply treatment is the only option—messages like “Addicts have to go to rehab or they’re going to die.” So, it can help (and relieve pressure) to remember that there are lots of ways to get help and support and effect change that don’t always include treatment.
Some people may want to get away from the consequences of consuming drugs or alcohol yet still may be hesitant, or ambivalent about getting formal treatment. Their first step might be reducing use or experimenting with abstinence on their own. Some will seek out a peer recovery support group, such as a 12-step meeting or SMART Recovery, while others will be more open to talking to a counselor. Or perhaps connecting with a certified peer mentor will feel like a good fit. Remember, one size doesn’t fit all.
It’s also true that professional care comes in many forms, including outpatient therapy (individual and/or group), intensive day programs (three to five days a week), sober living, inpatient residential programs and detoxes, and medications. Ideally, it also includes mental health and psychiatric care.
Ultimately, if you have a better understanding of the support options, you can make informed recommendations to your loved one and potentially lower their anxiety about what those options will look like.
To start, take a moment to think about which recommendations you might want to make to your loved one. As we’ve mentioned, our book Beyond Addiction includes a whole chapter on treatment options that may help you get the lay of the land, including these options:
- Going to a therapist
- Attending a peer support group
- Entering an outpatient or residential program
- Talking to a community elder or faith-based leader
Tips for Inviting Your Loved One to Get Help
As you prepare to discuss help options with your loved one, we’ll offer you some specific suggestions about how to make that go well.
Keep the following in mind:
- Your loved one’s behavior makes sense. Reflect on what they’re getting from their substance use to better target the help options that may be most useful to them. If you know that they struggle with anxiety or depression, for instance, maybe they would be open to seeing a therapist to deal with those issues as a starting point. If they’ve stopped using substances but are feeling isolated from their friends, perhaps they’d let you take them to a self-help support group where they could meet other people.
- It’s important to offer more than one option. Options increase the chances that your loved one will consider at least one of them. And don’t forget, you can always ask them what they think might be helpful.
- Try to provide the information you want to share without pressure or judgment, remembering the dynamics of ambivalence. Pressuring someone to accept your recommendations can make them defensive and more likely to argue against getting help.
- Speak directly to your loved one’s interests, even if you have a specific idea about what kind of support would be best. For example, getting help for employment problems or feeling down all the time may be more important to someone than seeking treatment for alcohol use. Even though the drinking might contribute to these issues, talking about the impact of substance use on their mood, job, health, or relationships may be more acceptable to your loved one than talking about stopping use.
- Talk about what they may gain by seeking help. For example, suggesting that medication might improve their mood or energy level could be more in line with your loved one’s goals than telling them medication will help them stop using.
- Think about ways to make your suggestions doable for your loved one. A small step forward can be less intimidating or threatening and result in more buy-in. So, you might propose a one-time consultation with a professional, for instance, instead of making suggestions that require more commitment, such as “starting treatment” or “getting sober.” Doable could even be as simple as an offer to drive them there.
When to Invite Your Loved One to Get Help
Remember, timing matters. Pick times when the invitation is more likely to be heard or when your loved one is more likely to think about change. For instance, talking about options over coffee on a weekend morning would likely go better than after an irritating day at work.
- Look for windows of opportunity—those moments when your loved one is feeling remorse or has expressed interest in making a change. Think about when (and where) they tend to be the most approachable. Is that in the morning over coffee? After dinner? Consider what else is going on in their life so that you can pick a good time to talk.
- There are also certain times to avoid, including when they’re high or hungover; are doing something that is important to them, like watching a favorite TV show or live sports; are rushing to do something else; or are irritable, tired, or not feeling well.
- Keep in mind your own emotional and physical needs and try to find a time when you’re less distracted, tired, or rushed.
- Resist the urge to get an immediate answer; give your loved one some time to digest what you’ve suggested. They may need to mull it over before deciding what to do.
- And finally, if their response to your invitation is a “no,” that’s okay; it doesn’t mean that all is lost. Remind yourself that this is a marathon and not a sprint. These conversations can evolve over time. The key is to stay connected and keep talking.