Matthew Goldenberg, DO
Founder of Professionals Health Solutions and assistant professor of psychiatry at Cedars-Sinai Medical Center.
Dr. Goldenberg has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
Robert is a 48-year-old executive who was suspended from his job after getting a DUI that was reported in a local newspaper. He was referred to you after completing a 30-day court-ordered rehabilitation program. When he comes to your office, he appears anxious and withdrawn, and he makes little eye contact. He reports a desire to stay sober, but admits to powerful cravings that are exacerbated by financial stress and family conflict. Robert tells you he’s required to attend recovery groups as a condition of his probation, but he’s not comfortable telling his story to “all those people.”
How can you help increase the odds that Robert, or any of your patients, will succeed in recovery? It’s a question many colleagues ask me. Here are eight key strategies that support long-term recovery.
Enhance your patients’ courage. Many people with substance use disorders may not think of themselves as brave, but it takes guts to face an addiction. These patients often fear detox, fear letting go of their primary coping mechanism (drugs or alcohol), and fear where their addiction could lead them. In many cases, they cannot remember or imagine a life without drugs or alcohol. You can enhance your patients’ courage by helping them identify and focus on pre-addiction accomplishments and achievements. For example, you might say to Robert, “Tell me about something you were good at, or something you accomplished in your career, before you began experiencing consequences from your drinking.” Prompts like these help patients remember they aren’t defined solely by their addiction. They have succeeded before—and they can do it again.
Use motivational interviewing. Individuals with substance use disorders are used to being lectured and threatened with consequences like jail—in other words, they’re used to people trying to externally motivate them. But recovery requires internal motivation, and this is much more effectively developed through a non-judgmental approach. Motivational interviewing invites patients to elaborate on their own reasons for wanting to stop using. For example, Robert may have 20 reasons to keep drinking and only one reason to stop. By asking him to discuss that one reason, you can help him overcome his ambivalence about quitting. (For more information about motivational interviewing, see CATR, June/July 2016.)
Educate patients about 12-step programs and support options beyond those programs. Many recovering individuals seek support in 12-step meetings, but they don’t resonate for everyone. I suggest you let your patients know early on that there are other mutual self-help options, such as SMART recovery and Refuge Recovery meetings. (For more information about alternatives to 12-step programs, see the upcoming June/July issue of CATR.)
Encourage sober friendships. Many addicts fear they will lose their friends and community once they enter recovery. They need to know about recovery’s silver lining: It helps them find out who their real friends are. I encourage my patients to strengthen relationships with old friends who support sobriety, and to make new friends who embrace a healthier lifestyle.
Teach healthy coping skills. For many patients, their substance of abuse is their primary coping skill. If they don’t replace that substance with something else that works, they’re unlikely to succeed at sobriety. Teaching your patients tools like mindfulness, meditation, exercise, journaling, talking to a friend, listening to music, or doing other stress-relieving activities can help them cope with strong emotions. Core mindfulness skills from dialectical behavior therapy (DBT) can be a great place to start, because DBT has a growing evidence base and there are enough skills that most patients will find something that works for them. (For more information about DBT mindfulness skills, see CATR, August 2016.)
Teach honesty. Many people with substance use disorders are ashamed to admit they have a problem, and this can make it hard to be honest about the struggles they are facing. Reminding patients you’re there to help, not to judge, can encourage them to develop a foundation of trust with you. One useful tool is to ask patients to write a letter expressing their uncomfortable thoughts and feelings about addiction, and then not send it. This exercise promotes honest expression without fear of judgment or other repercussions; it is actually a form of exposure therapy. The goal is to desensitize patients to their anxiety about telling the truth, and ultimately to help them find their authentic voice and allow it to be heard.
Encourage service to others. Being of service to others is part of the 12th step in AA. This service can involve becoming a sponsor to other members, giving talks, and volunteering in the community, among other things. Such activities can promote patients’ recovery.
Identify relapse triggers. Relapse prevention is a set of techniques for recognizing triggers to use, learning to avoid them, and practicing how to deal with tempting situations without giving in. For example, let’s say Robert’s line of work requires him to meet with clients in settings where alcohol consumption is often expected. For him, relapse prevention might involve role-playing how to say “no” in a way that would save face and appear socially acceptable in those situations. (For more information about relapse prevention, see Melemis SM, Yale J Bio Med 2015;88(3):325–332.)
I teach patients that physical relapse—the act of drinking or using drugs—is usually preceded by mental or emotional relapse. Mental relapse usually happens when patients place themselves in situations where they are likely to give in to temptation, such as spending time with friends who use. One of my patients used to put it this way: “How many times can you go into a barber shop before you get your hair cut?” For many patients who expose themselves to triggers, it’s only a matter of time before they convince themselves they can handle just one drink or hit. After that, physical relapse is almost inevitable.
While mental relapse involves patients exposing themselves to risky situations, emotional relapse happens when patients let their emotional “resistance” to those situations weaken. This most often results from neglect of basic self-care measures—adequate nutrition, getting enough rest, exercising, and finding healthy outlets for stress. It’s easy for patients and doctors alike to forget the importance of self-care, so I make a point of asking about it at every visit.
CATR Verdict: Keeping these eight strategies in mind will help you improve the chances that patients like Robert will succeed in recovery.