At the level of the individual patient, no two addictions are the same, and so no two treatment plans will ever be identical. But some strategies have proven more effective than others. In her commentary in today's New York Times, Dr. Sally Satel addresses the idea of the firm hand in treatment. She writes:
Strict monitoring, with predictable and meaningful consequences, is so often the best medicine for people with addictions...
Swift response to infractions drives home the message that actions are taken seriously and that the addict controls his fate. Also, sanctions decrease the dropout rate from treatment.
While she writes more specifically about treatment in a criminal justice sphere, these same strategies are used very successfully in treating addicts in a clinical environment. In our New York office, a firm hand often comes in many forms: a breathalyzer left in the therapist's desk for testing before sessions or at randomly selected times, patient's surrendering their funds to therapists who control access to credit cards and bank accounts until trust has been regained or even drug tests in extreme cases.
But as Dr. William Hapworth, who has treated many addicts in various settings throughout his career, points out, these types of measures should only serve as a support to the doctor-patient relationship. "A key to understanding an addict is establishing a rapport with a patient over time and knowing his patterns. That is why it is so important for a patient to see one therapist over the course of treatment. Through the relationship, the therapist will begin to understand the motivations and the situations that will precipitate urges to use."
Dr. Hapworth sees drug testing as a very ineffective tool in the treatment process as he has never ordered a drug test that he wasn't sure of a positive result. As Satel says, it is still important that the patient understands that the test will be administered and that there will be real repercussions for the failure, but a deep understanding of the patient should render the test itself virtually pointless. Dr. Hapworth emphasizes that "compulsory drug testing should not take the place of individual or group long-term treatment, in the first year of recovery showing up is 90% of the battle and any departure from showing up should be seen as big trouble no matter what the excuse maybe".
Satel sees coercion as a useful tool, and one that makes a client's desire to be clean almost meaningless. While in a punishment setting, this type of thinking is more valuable, in the clinical environment there must be more of a back and forth. Dr. Hapworth believes that every addict has his or her leverage points and these should be used to promote recovery. Certainly, a good therapist will use coercive measures to help a client move toward a better place, but understanding his patterns and defining the people, places and things associated with abuse can often prove more effective. Dr. Hapworth adds "Any loss of sobriety as the priority in the first year is a sign of relapse risk, drug dreams are an indication of imminent risk and addicts should report them immediately, but a most important relapse signal is the addict's tendency to isolate and not reach out to other people in recovery. The addict should form a network of people who are sober references and be open to their confrontation without responding defensively at the center of this network should be the addict who is ready willing and able to be challenged to prove his or her actions". This scenario varies from addict to addict but in the first year becomes a battle of great magnitude with high stakes for the addict and their loved ones.
Addiction is best tackled from multiple angles: AA or NA meetings, small group sessions and 24/7 support in an online environment. Each of these provides specific buttresses against urges to use. With these networks in place, and the stern backing of a treatment specialist, clients can and will achieve positive outcomes.
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