How to choose addiction treatment

Learn about your options!

Last update, 4/8/07

This article provides information to individuals seeking treatment for themselves, as well as their loved ones.

Are you seeking residential or outpatient treatment?

If you are googling addiction treatment (for alcohol, drug, gambling or similar problems), you are probably looking for residential treatment. If you are looking for outpatient treatment, which usually happens close to home, go to:

            http://findtreatment.samhsa.gov/

This federal government website lists over 10,000 treatment centers.  It is the most comprehensive facility list.  Although this free report is primarily focused on helping someone choose residential treatment, the guidance below also applies to outpatient treatment.

Definitions

In residential treatment you live in the facility while in treatment.  The typical program is 28 or 30 days, but longer term residential treatment is also available. In outpatient treatment you live at home and attend treatment a few or many hours per week.  Structured programs have a set schedule (e.g., 3 hours a night, 3 nights a week, 6 weeks).

Residential treatment is not identical to inpatient (or hospital) treatment.  There are few hospital programs available anymore because treatment in that setting is very expensive to provide.  For instance, a hospital must provide nursing staff 24 hours per day.  Most participants do not need that level of care.

Residential treatment is also not identical to detoxification (or “detox”), although it may begin with a detox.  Detox (or withdrawal) is the period of time it takes your body to adjust to not having your substance, if your substance is alcohol, an opiate (heroin, methadone, opium, Vicodon), a benzodiazepine (Valium, Xanax) or other depressant (as in central nervous system depressant).  Detox takes 3 to 10 days typically, depending on the substance and your history with it, your overall health, your age, and other factors.  Detox is often accomplished in a hospital ward devoted to detox only.  People get medical detox for two reasons.  Prescribed medications can make the process easier, and simply going “cold turkey” (stopping your addictive substance suddenly) can make you very sick or even kill you.  Therefore, even if you do not wish to have treatment for the addictive behavior itself, it is safest to seek medical attention for the detox process.  Even stimululants (cocaine, amphetamine) have a mild detox syndrome, but do not require medical attention. 

Alternative detox methods are gaining recognition, including using an IV to “bathe the brain” in amino acids, and detox under anesthesia.  These methods are beyond the scope of this article.

General guidelines

1. Let the buyer beware (in Latin, caveat emptor).  The addiction treatment industry is highly competitive.  Marketing claims may not be backed up by solid evidence.  Is the claim a program is making based on studies published in the scientific literature?  For instance, “success rate” is a term not typically used in the scientific literature, because  actual treatment outcomes usually range from very poor to very good.  It is not sensible to divide that range into just two possibilities, success and failure.  Most scientific studies will report the outcome range in at least several groups, such as: worse, not improved, slightly improved, significantly improved.  Even those in the improved groups are not necessarily abstaining.  Furthermore, reports by the clients themselves are usually confirmed by drug testing and reports by a family member.  Treatment centers cannot afford to conduct their outcome studies with these confirmations, and that’s why you don’t see their claims of success actually published in scientific journals.  A treatment center that claims high success can still be good, but you’ll need to look beyond the success rate to know.

2. Residential treatment may be helpful, but may not be essential.  The reason almost all insurance companies have stopped paying for residential treatment is that the effectiveness of residential treatment and outpatient treatment have been compared over two dozen times.  For clients who can afford residential treatment, it works no better in the long run than outpatient.  For clients who cannot afford residential (e.g., they are homeless), it is often better than outpatient, apparently because it provides the stability otherwise lacking in their lives.  Residential treatment appears to be most useful when someone has attempted to make change and cannot seem to manage it in their normal environment.  Remember, however, that after treatment they will need to return to their home environment, and it often happens that problems quickly return. 

3.  Unless it is obvious that getting the individual into a secure environment needs to happen immediately, start with outpatient treatment.  In outpatient treatment there is no problem of what happens when the individual returns home, and outpatient treatment is often much less expensive (especially considering that your insurance may pay for some of it).  If change is not happening quickly enough residential can be the backup plan.  The push for residential treatment often comes from the family, which is desperate for relief (“just get him out of here and safe, so life can be better for awhile!”).  In these situations, however, the individual may often have great resistance to residential (“I don’t need that, I can do this on my own.  And I can’t afford to be away that long”).  The family response can be that as long as there is (progress, abstinence, successful moderation, etc.), they will not insist on residential, but will if there isn’t.  For basic guidance on how to insist, see below, on family attitudes.

4. Stay focused on the desired outcome, not the process.  Many people reading this report are family members, hoping to find the “right” treatment for a loved one.  Rather than insisting that your loved one do this or that (some treatment program you think will be helpful), focus on what you really want: no more (or at least fewer) addiction problems.  Don’t get so caught up in the process of treatment that you lose sight of the goal.  Let your loved one determine what might be helpful.  Any program the user chooses is better than one forced on him or her.  As mentioned, starting with local outpatient treatment often makes more sense than going off for 28 days.  In many cases simply entering individual psychotherapy will be sufficient.  Don’t hold your loved one accountable for going through the motions of change, stay focused on the outcome you desire.  In other words, “I’m going to treatment just like you wanted me to” should not be allowed to excuse misbehavior.  If it is available in your community, sign yourself up for CRAFT (Community Reinforcement and Family Training).  These sessions will teach you how to take care of yourself, reward positive behavior in your loved one, and induce your loved one to enter treatment if it is still needed.  Remember also that change without treatment is entirely possible.  Treatment centers rarely say this (it’s not good for business), but it’s an easily made observation.  Smokers rarely attend treatment to change, but tens of millions of US residents have quit smoking.  Is it easy to quit smoking?  Of course not!  You might object that intoxicating substances are different that cigarettes.  To a degree, yes, but many who have quit cigarettes and also a more intoxicating substance report that even though the intoxicant was more fun, the cigarettes were harder to stop.  So, stay focused on the outcome you want, and let your loved one focus on how to get there.  Also, do not hesitate to establish timeframes for the changes needed.  Otherwise you may hear “I’m working on it” for a very long time.

5. Family attitudes are often part of the problem.  A dysfunctional family attitude often shows up in statements such as “if he/she would just change then everything would be ok.”  The way to change the behavior of others is to change your own.  For your loved one to change his/her addictive behavior may require significant change in yours.  Are you ready to maintain communication and a loving attitude, but set firm limits about certain behaviors?  This is not the same as “tough love:” get out, come back when you are fixed.  Some families have used that approach and seen disaster occur.  For instance, if you kick your child out, how will you feel if homelessness leads to being beaten badly or murdered?  In many cases the place for the family to start is with their own treatment, to gain the strength to maintain the balance just mentioned: communicative and loving on the one hand, but firm on the other.  Quite simply, if your perspective is “it’s his/her problem, I’m not the one who needs treatment,” perhaps you are not truly ready for the change you say you want?  The right firm limits are often rather difficult to establish.  There is no shame on seeking professional help to figure out the big picture: what you should reward, what you should ignore, and what you should set boundaries about (and possibly punish).

6. Don’t spend all your money on the first round of treatment.  There may be several rounds needed.  Start small.  If that doesn’t work, step up the intensity gradually if possible.  Don’t overlook inexpensive or free resources, such as self-help books or support groups.  Many support activities are now available on the web.

7. There are many approaches to recovery, not just what is typical in the US (but not in other countries):  a combination of the 12-step approach, and the idea that addiction is a disease.  Almost all US addiction treatment is based on this combination. The 12 steps are those of Alcoholics Anonymous (AA).  There are now approximately 200 additional “12-step” groups, such as Narcotics Anonymous (NA) and Cocaine Anonymous (CA).  If you read the 12 steps (printed below) you can easily see that it is an approach that will not be of interest to everyone.  Unfortunately, many treatment professionals are not forthcoming about the alternative options that are available.  A good place to get information about alternative treatment options is the websites of the alternative support groups.  These groups are also listed below.  Their programs of recovery are quite different from the 12 step approach.  They deserve wider recognition, but many treatment professionals seem committed to suppressing information about them.  Ask a 12-step oriented professional about alternative approaches and you’ll often be told something like “12-step is the only thing that works.”

To be clear, the 12-step approach works well for some people, especially if they have freely chosen to attend it.  However, the statement that “12-step is the only thing that works” is simply untrue.  Although some treatment professionals will utter this statement in a highly convincing way, in this case sounding convincing does not equal being accurate.

The most comprehensive review of treatments for alcohol is found in The Handbook of Alcoholism Treatment: Effective Alternatives (3^rd ed.), edited by Hester & Miller, published in 2003 by Allyn & Bacon.  All randomized, controlled clinical trials of alcohol treatment that were available in the scientific literature at that time were reviewed and compared to one another.  A summary of the findings is at Dr. Hester’s website (he’s listed at the bottom of the home page):

http://www.behaviortherapy.com/whatworks.htm

Notice that treatment based on AA, and AA itself, are numbers 37 and 38 on this list.

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THE TWELVE STEPS
OF ALCOHOLICS ANONYMOUS

1. We admitted we were powerless over alcohol ﾗ that our lives had become unmanageable.

2. Came to believe that a Power greater than ourselves could restore us to sanity.

3. Made a decision to turn our will and our lives over to the care of God as we understood Him.

4. Made a searching and fearless moral inventory of ourselves.

5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs.

6. Were entirely ready to have God remove all these defects of character.

7. Humbly asked Him to remove our shortcomings.

8. Made a list of all persons we had harmed and became willing to make amends to them all.

9. Made direct amends to such people wherever possible, except when to do so would injure them or others.

10. Continued to take personal inventory and when we were wrong promptly admitted it.

11. Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out.

12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

From http://www.alcoholics-anonymous.org

Non-12-step (non-religious) support groups

All are abstinence oriented (except Moderation Management).  All are non-profit.  All have active websites, but not many face to face meetings.  Rational Recovery no longer offers support groups (as of 1/1/2000).  Listed below in order of longevity, oldest first.

Women for Sobriety

http://womenforsobriety.org/

Secular Organizations for Sobriety

http://sossobriety.org/

Moderation Management

http://moderation.org/

SMART Recovery

http://smartrecovery.org/

LifeRing Secular Recovery

http://www.unhooked.com/index.htm

8. Don’t doubt yourself if you view addiction as NOT a disease.  Despite the heavy publicity attempting to persuade the public that addiction is a disease, most people still don’t believe it.  If you DO view addiction as a disease, finding treatment compatible with that view is easy.  There are even some programs that are disease oriented but not 12-step oriented.  Finding a non-disease, non-12-step program takes a little more searching, but they exist.  From a non-disease perspective, free will over your addictive behavior is something you develop with practice, and can practice instantly any time it’s important enough.  The problem is that choosing not to use needs to be perceived as more important!  In most cases the individual in fact holds family, God, work, various ideals or other ultimate values as more important than addiction, but in the swirl of thinking surrounding a craving these ultimate values are easily lost sight of.  Regardless of whether a treatment program is disease or non-disease, effective treatment usually helps create new habits in this area.

9. In addition to the support groups listed above, which primarily take a psychological approach or traditional medical approach (often including medication), there are alternative health interventions which may be helpful as an addition to treatment, or as the primary treatment.  Examples include acupuncture, energy healing, ayurvedic medicine, etc.  These methods are beyond the scope of this article.  

10.  There is great diversity in the psychological and medical approaches used by treatment centers, so they should not be assumed to be identical.  For many individuals the choice of a treatment facility will largely be determined by cost and location.  Nevertheless, you will still likely have several facilities on your final list, and the guidelines here can be of assistance in choosing between them.  It has been said that on any given Sunday any pro football team can beat any other.  On the right day even the worst team can beat the best.  Addiction treatment may be similar.  Every facility helps some people.  Pick a facility that seems most compatible to you.  Work its program diligently.  If you discover (after a reasonable length of time) that the program isn’t working as you, you can always try another approach.  Far and away the greatest virtue in changing addictive behavior is persistence.  Those who persist will eventually succeed!

11. If you have been ordered to treatment by the government (a court, prison, probation officer, licensing board diversion program, etc.), you have the right (in about 20 states) not to attend a 12-step based program (although you can still be required to attend some type of treatment).  Four US Circuit Courts of Appeal (the 2^nd, 3^rd, 7^th and 8^th) have ruled that 12-step groups are a type of religious exercise. The establishment clause of the Constitution’s 1^st Amendment states that “Congress shall pass no law respecting an establishment of religion, nor prohibit the free expression thereof.”  Enforcing this right may be difficult, and consequently not practical.  For a review of this issue, published in the Duke Law Journal, see:

http://www.law.duke.edu/shell/cite.pl?47+Duke+L.+J.+785

12. Treatment needs to address underlying issues and concerns, as well as the addictive behavior itself.  For a good list of what addiction treatment would do well to include, see the list below, published by the National Institute on Drugs (a federal agency):

http://www.nida.nih.gov/PODAT/PODAT1.html

Notice the first point listed there, that no treatment approach is going to work for everyone.  The 13 principles listed are based on a review of drug treatment, vs. the book mentioned above on alcohol treatment (edited by Hester & Miller).  However, there are many similarities between the effective treatments listed in each book.

About the author:  I have written this article for two reasons.  1) The public continues to be presented with significant misinformation about addiction and its treatment.  My hope is that if individuals needing to change addictive behavior, and their families, are provided with accurate information, they will change more quickly and completely.  Everyone benefits when this occurs.  2) Some who read this article will be interested in reading about the treatment center I founded in 1985, Practical Recovery Services. Our home page is:

http://www.practicalrecovery.com

My bio is at:

http://www.practicalrecovery.com/ourstaff.html#tom_horvath

Please send me your questions and comments.  I do not promise to respond to all posts, but I will consider all of them.  This article is an ongoing work, and I hope to make it ever more useful based on the feedback I receive.

Tom.Horvath@practicalrecovery.com

Thank you!