Personal Resources

New year in recovery

How to Start the New Year off Strong in Recovery

With any start to a new year, this is the perfect opportunity to start fresh and to set realistic goals for yourself.

A new year is the symbol for hope and new beginnings and if you are a newly recovering addict, this is a crucial time in your recovery journey. It’s so important to start this year off with an action plan for how you will preserve your sobriety. You can learn the tools for success in addiction treatment, but it’s how you apply these tools in the everyday setting that truly matters. At Behavioral Health of the Palm Beaches, we understand the importance of setting attainable recovery goals for the new year. We provide individualized addiction treatment services in Palm Beach for all who are battling with substance abuse.

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How to Avoid Drug Cravings this Holiday Season

While the holidays are filled with numerous celebrations and happy moments with your loved ones, recovering addicts may have a hard time navigating this time of year.

The holiday season can spark triggers when individuals encounter parties and celebrations with alcohol, and this may bring about a great deal of stress. You also may feel extra pressure to make the holidays perfect and this can lead to a potential relapse. You can still enjoy the holidays this year while maintaining your sobriety, and there are ways to avoid drug cravings. Behavioral Health of the Palm Beaches is here to help you stay on track this holiday season, and here we provide tips for avoiding drug cravings. A sober holiday season is possible!

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Eliminating Stigma From the Inside Out

Eliminating ‘Stigma’ From the Inside Out

Eliminating Addiction Stigma

We seem to be constantly trying to change the public’s perception of substance use disorders and of people with substance use disorders. At best progress is slow. The terms “stigma” and “shame” have a lot in common. “Stigma” may be what is inflicted upon us by others. “Shame” is what we carry.

We’ve been trying to change the world. That’s hard to do. It’s easier to “have the courage to change the things we can.” Is it possible that we create at least some of the “shame” that feeds the stigma? It’s possible that we do.

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Social Anxiety Disorder and Alcohol Use: I’m SAD! I need a drink!

Being sad is one thing, but suffering from social anxiety disorder (SAD) is a totally different ball game. This is the same way that “wanting” a drink differs from “needing” a drink. When joined with problem drinking, this forms a lethal combination.  For a long time, experts have witnessed that people with anxiety disorders are susceptible to substance abuse and vice versa, but determining which one is the preceding problem has been a stumbling block for diagnosis.

More than just shyness

An individual suffering from social phobia, also known as social anxiety disorder (SAD), has a distinct and sometime irrational fear or anxiety about specific circumstances. According to WebMD, some of these situations include:

  • Speaking in public
  • Eating or drinking in front of others
  • Writing or working in front of others
  • Being the center of attention
  • Interacting with people (i.e. dating, attending parties, etc.)
  • Asking questions or giving reports in groups
  • Using public toilets
  • Talking on the telephone[1]

What causes SAD? Many researchers believe that it might be related to the abnormal functions of the brain circuits that regulate fear and anxiety. Genetics is also thought to play a part in its roots, since social phobia occasionally runs in a family. Other factors include stress and environment.[2]

The fear of making a mistake or humiliating oneself in front of others can be debilitating to a person with SAD. Taking a drink to calm one’s nerves is often used as a coping mechanism.

More common and costly than you think

Anxiety disorders, which affect over 40 million adults (or approximately 18 percent of the population), are the common mental illnesses in the United States.[3] According to the Anxiety and Depression Association of America, an estimated 15 million Americans suffer from SAD.

The disorder often surfaces during the teenage years or early adulthood and is more prevalent in women than men. Although highly treatable, sadly, only one-third of those suffering seek professional treatment.[4]

The economic costs associated with anxiety disorders in the United States are overwhelming. In the 1990, the costs were estimated to be around $46.6 billion. The majority of the expenditures was tied to the loss and reduction of productivity and other indirect costs, instead of treatment.[5]

Symptoms and signs

The symptoms that a person who is suffering with SAD experiences can vary and be difficult to distinguish from other health issues, such as depression and obsessive compulsive disorder. These individuals tends to have negative thoughts about themselves and what will happen to them in social situations. According to the National Institute of Mental Health, some of the common signs are:

  • Anxiousness – especially about being with other people
  • Self-consciousness – worried about how they are perceived by others
  • Extreme fear of embarrassment
  • Excessive worrying – sometimes for days and weeks before an activity
  • Avoidance of places where people hang out in crowds
  • Difficulty establishing and maintaining relationships

Physical signs, which include:

  • Blushing
  • Heavy sweating
  • Increased heart rate
  • Trembling
  • Nausea
  • Hard time talking[6]

Self-medicating

Even after diagnosis, individuals are often leery about seeking professional help. They underestimate the seriousness of their condition and believe that they can fix the problem themselves. Instead of seeking mental health treatment, alcohol and other substance are often used for self-medicating an anxiety disorder. Researchers are investigating just how frequently people are using and abusing self-destructive alternatives to deal with SAD and other anxiety-based disorders.

Individuals self-medicating an anxiety disorder are two to five times more likely to develop an alcohol or drug problem within three years.

A 2011 longitudinal study that includes almost 35,000 U. S. adults revealed that 13 percent of those who had consumed alcohol or drugs during the previous year had done so in order to relieve anxiety, fear or panic. It also found that individuals with a diagnosed anxiety disorder who were self-medicating at the beginning of the research were two to five times more likely to develop an alcohol or drug problem within three years than people who did not self-medicate.[7]

Other results from the three-year study showed that the number of people with an anxiety disorder who developed a substance problem varied depending on the self-medicating substance:

  • With alcohol use – 13 percent developed an alcohol problem
  • With recreational drugs use -“ 10 percent developed a drug problem

A drink won’t help

One of the most frequent self-medicating techniques is alcohol consumption. Individuals turn to alcohol because it help them feel more in control of a given situation or encounter. It also lowers inhibitions and reduces self-consciousness.  In some social gatherings, such as parties and mixers, alcohol is available in abundance.

A 2012 study at Emory University investigated the relationship between SAD and the motives for drinking. The researchers believed that the reasons for drinking are based on the fact that people drink in order to achieve an outcome that is of value to them. The motives can be categorized as:

  • Social: Drinking to aid camaraderie
  • Enhancement: Drinking to have more confidence or to enhance the impact of another drug
  • Coping: Drinking to cope with or escape from stress

The results showed that 13 percent of the participants met criteria for SAD at some point during their lives. It was determined that SAD was a predictor of coping drinking motives, but was not a predictor for social or enhancement motives. The research also revealed that other mood disorders (i.e. depression, panic disorder, and generalized anxiety disorder) also lead to coping drinking motives. [8]

Short-term solution, long-term problems

Self-medicating anxiety with alcohol makes things worse in the long term.Drinking alcohol is only a short-term solution for suppressing anxiety. Initially, drinking may make an individual suffering from SAD have less tension and feel more confident in social situations. However, once the “buzz” wears off, the old anxiety returns. Dr. James M. Bolton, lead researcher in a 2011 study about the effectiveness of alcohol in treating anxiety, stated: “People probably believe that self-medication works. What people do not realize is that this quick-fix method actually makes things worse in the long term.” [9]

Alcohol is a depressant and has an overall detrimental effect on the central nervous system. According to the National Institute on Alcohol Abuse and Alcoholism, regular alcohol use can lead to long-term health problems such as:

  • Stretching and drooping of heart muscles (cardiomyopathy)
  • Irregular heartbeats (arrhythmias)
  • High blood pressure
  • Liver disease/inflammations
  • Certain cancers (mouth, esophagus, throat, liver and breast)
  • Weaken immune system [10]

Additionally, alcohol can interfere with the thinking process. Drinking a couple of glasses wine before a presentation may seem like a way to lessen tension. However, that consumption can lead to making errors and possibly fumbling through the talk, which could increase the anxiety for any future communications. Thus, this compels the anxiously-minded individual to drink even more alcohol and starts a vicious cycle that is difficult to break.

Alcohol is not the answer

If you suffer from SAD, don’t make the mistake of trying to eliminate your problems with alcohol alone. SAD is a psychological disorder and should be treated by medical professionals.  Treating SAD with alcohol leads to additional problems that can destroy relationships with families and friends.

If you or a loved one has already started self-medicating with alcohol, the experts at Behavioral Health of the Palm Beaches can help. Our alcohol detox program in Palm Beach can be your first step. With nearly 20 years of experience, our doctors can develop a treatment program that gives you better options to deal with your anxiety issues. Alcohol is not a safe and healthy way to deal with anxiety. Call us at (888) 432-2467 for healthier possibilities.

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SMART/12-Step: It’s not a contest.

A few months ago we began to offer a weekly meeting of SMART (Self-Management and Recovery Training) at Seaside Palm Beach as another tool in the arsenal that a person in recovery can use to maintain abstinence from addictive behaviors.  Twelve-step recovery meetings continue as they always have. The weekly Smart meeting has become popular. I can say that a number of people have integrated SMART into their long range plan for continued abstinence.

I was a little bit surprised at the impression a few people had of SMART even before we offered to first meeting. One person said “when I get to the point that I really want to drink I’m not going to do a cost-benefit analysis.” He’s probably correct. However, as I pointed out, “you’re not likely to call your sponsor either.” It doesn’t matter if a person is using 12-step recovery, SMART, or some combination, the reason we use meetings for support is so we don’t get to that point.

It is true that where 12-step recovery is based on spiritual principles SMART is based on Cognitive Behavioral Therapy (CBT). A SMART facilitator may tell the group that “spirituality is not part of the SMART program.”

I’m a SMART facilitator and a long time believer in 12-step recovery. I’m good at manipulating. So, if a person brings up “spirituality’ at one of my SMART meetings I will ask “what are the needs you are looking to fulfill?” I will then gladly put items such as belongingness,” “rootedness,”  “the desire to be a part of something bigger than oneself” on the agenda for the evening.

It also occurs to me that if there’s no need for a Higher Power, what do you call a group of people supporting each other?

On the other hand, “came to believe….” seems fairly cognitive to me.

There are clearly people who object to 12-step’s religiosity. Probably the worst thing someone can do is tell another that 12-Step is not religious.” It is! I’ve often wanted to tell non-believers to “get over it.”  Most of the time they don’t. So for some people SMART may be the only social support for recovery. That would be great if SMART was as geographically available as is 12-step recovery. It’s not even close.  Fortunately, SMART has a great website (www.smartrecovery.org).

Great websites are also available to support 12-step recovery (www.intherooms.com ).

Bottom line is that SMART is not something that is offered instead of 12-step recovery. It’s “in addition to.”

Is an addiction a disease? SMART recovery does not take a position. Alcoholics Anonymous (AA) makes reference to an allergy to alcohol. Does it make a difference when it comes to maintaining abstinence? Probably not. In any case, it’s unlikely that a group of recovering people is going to settle an issue. It takes a lot of energy to maintain abstinence. Leave the argument to scientists.

The goal of SMART recovery is abstinence from addictive behaviors. It does not advocate moderation. It is true that SMART meetings are open to people who have not yet decided to abstain from addictive behaviors. People who have yet to make that decision are welcome providing they are not disruptive.

AA is open to anyone with a “desire not to drink.”AA is open to anyone with a “desire not to drink.” AA is likely to attract some people still engaged in the addictive behavior. They need to have the desire. That’d not a stipulation of SMART recovery.

Point is that both SMART and 12-step recovery may attract people who are still using. I think that SMART attracts a few more. Whether that’s a positive or a negative is debatable.

What’s not debatable is that SMART is less shaming. People who find labeling (“my name is …….., I’m a…..”) will feel much more comfortable at SMART.

In 12-step recovery there’s an emphasis on “powerlessness.”  SMART emphasizes being “empowered.” The difference may not be as great as it seems. It can be argued that accepting “powerlessness” over an addictive behavior actually frees you up. A good number of people will reject this argument.

I see pluses and minuses regarding SMART’s use of trained facilitators. The thirty hour on-line certification process is very well done. My experience has been that SMART facilitators are very professional. I’m not sure that the thirty hour process screens out people who shouldn’t be facilitating groups.

I believe that participants in a SMART group attribute skills to a facilitator that go beyond what the facilitator is trained to perform.

However, sponsors in 12-step programs are frequently seen as having magical powers.

The thing to remember about 12-step and SMART is that they are both support groups, not professional help.

So what does it come down to? My belief is that when a person is ready to give up an addiction petty arguments about whether one support group being spiritual and another cognitive will go away. That being said, a person has to start somewhere. Whether it’s 12-step or SMART it really doesn’t mater. A person working a strong recovery will find comfort in both.

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young woman patient sitting on female therapist couch bonding during their session

Forming Therapeutic Alliances

Way back in 2000 it was my job to begin to develop internship relationships with local colleges and universities. Dr. Tammy Malloy has fully developed that program here at Behavioral Health of the Palm Beaches. It continues to be among the best examples of how treatment centers and universities can work together and how students can grow into professionals.

The obvious way to begin relationships with schools offering Masters Degrees in Marriage and Family Therapy, Mental Health Counseling, Social Work, and other quality graduate degrees in the helping professions is to contact the people coordinating internships at each college or university. I was surprised that a few of the people whom I contacted told me that they did not place interns in organizations treating addictions. The reason given was the perception that therapists working in facilities like Behavioral Health of the Palm Beaches (BHOPB) lacked a full range of counseling skills.

Fortunately, that perception has changed signifcantly since 2000. Today, BHOPB therapists are recognized as being very well trained and capable of employing a wide range of counseling skills using evidence based treatment. This is evidenced by the number of quality colleges and universities who have been placing interns at BHOPB over the years. A number of administrators, managers and therapists currently working at BHOPB began their journey as interns.

Often in the beginning of the treatment process there maybe some disconnect between the goals of a patient and those of a therapist.

Way, way back, when I was fairly smug about the professional work that I was doing a wise physician said to me, “If you ever think that you can’t get better, you’re in trouble.” As good as we are we can always get better.

To this day there may be some disconnect between the goals of a patient and those of a therapist. We are an outstanding organization that treats substance use disorders (SUDs). It seems natural that our goal is to help a person to stop engaging in addictive behaviors. That may not be, and often isn’t, the major goal of our patient.

A good example of the goal of the patient and the goal of the therapist not aligning is whenever the patient’s primary goals are only to:

1.    Stay out of jail

2.    Reduce drug usage to a moderate level so they don’t lose their girlfriend, boyfriend, husband or wife

 

A ‘Therapeutic Alliance’ is nothing more than an agreement between a patient and the therapeutic team on goals, strategies, and methods.

The point is that, in spite of all the good work that we do, we sometimes fail to develop a Therapeutic Alliance (ASAM, 2013; Claunch et. al., 2015) with our patients. A ‘Therapeutic Alliance’ is nothing more than an agreement between a patient and the therapeutic team on goals, strategies, and methods.  However, to have this ‘agreement’ you have to build trust. How can you build trust unless you’re both driving on the same road? Building trust in the therapeutic relationship is what fosters the Therapeutic Alliance (T.M.).

If my goals are to stay out of jail and to keep a girlfriend and my therapist’s goal is to get me to stop using, there’s a conflict. The conflict took some time to resolve but we had to work it through, get over some anger, and it took some time.

It would have taken a lot less time and conflict had my therapist, from the start, accepted my goal and helped me to realize that I had no hope of remaining free or maintaining a relationship unless I stopped using.

It would be no different for the lady who wants her children back or a man trying to keep his job. In other words, form a ‘Therapeutic Alliance’ from the get-go.

Two-way feedback is a necessary part of the therapeutic process.

Developing the alliance is very dependent upon the patient receiving frequent feedback regarding their progress or lack thereof. Barry Duncan et. al. (2009) have developed ‘Feedback Informed Treatment (see: FIT/info@fitoutcomes.com).’ A number of organizations are either using or adapting the principle of immediate feedback. FIT Outcomes provide examples of Session Rating Scales (SRS) and Outcome Rating Scales (ORS). Immediate feedback can become available to both patient and therapist following each session (SRS) and each intervention (ORS). A patient cannot change unless the patient knows what to change. Don’t we want to know if the road we are on, together, is the right road and that the intervention we are using will prevent the car from breaking down? Two-way feedback is a necessary part of the therapeutic process.

Ever been in a hospital? The lack of information can drive you nuts!!

Think about what you may be looking for from your supervisor. Have you ever received unexpected feedback after six months or a year?  Not fun? Behaviors could have been changed had you known sooner.

Earlier when that physician said to me, “If you ever think that you can’t get, better you’re in trouble,” it really pissed me off! A good indicator that something needed to change.

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Don’t Gamble with Your Sobriety on Super Bowl Sunday

Super Bowl Sunday brings the opportunity to combine two favorite pastimes: football and excessive drinking.The big game is rapidly approaching and plans are being made for which drinking game will be used. Will this be the year of, “Every time Peyton Manning says Omaha, take a shot?” Or, will it be “Take a swig every time Cam Newton poses for the camera?” No matter whether the Denver Broncos or the Carolina Panthers are running a play, many Super Bowl parties will feature substantial amounts of drinking.

Every year, Super Bowl Sunday brings together millions of Americans with the opportunity to combine two favorite pastimes: football and excessive drinking. No one thinks about ensuing impairment possibilities or the thousands of calories being consumed.  Getting together with friends, watching funny and innovative television commercials, having quite a few drinks and hopefully seeing a decent football game are the defining moments of the Super Bowl. How will you prepare for this year’s event and still be at work bright and early on Monday morning?

A short game: a long drinking window

Alcohol on Super Bowl SundayIn America, Super Bowl Sunday is second only to New Year’s Eve in alcohol consumption. According to a recent article, approximately 50 million cases of beer are consumed on this day.

While the game only last for four quarters, bad drinking decisions can last a lifetime.

On February 7th by the time that Super Bowl 50 starts in Levi’s Stadium in Santa Clara, California, people will have been bombarded with endless hours of pre-game festivities and stories. In between sport casters’ analyses, the day is often filled with heart-warming comeback stories. During childhood anecdotes from running backs and cornerbacks, a drink or two makes the time pass.

According to Bloomberg, the average length of a Super Bowl broadcast over the past two decades is only three hours and 35 minutes.  However, with the additional events included, over six hours are easily spent watching the game, chatting with friends and drinking an exorbitant amount of alcoholic beverages.

Safe habits for the big day

Driving when even only slightly impaired can result in serious injury or loss of life.Too many drivers out there believe that having just a few drinks and getting behind the wheel of a vehicle is harmless. But statistics don’t lie.  Driving when even only slightly impaired can result in serious injury or loss of life.  These not only affect the lives of the impaired driver but can affect other families as well.

According to data from the National Highway Traffic Safety Administration (NHTSA), on Super Bowl Sunday 2012 alone, 38 percent of fatalities from motor vehicle crashes have been connected to drunk driving, compared to 30 percent on the average weekend.  Their yearly campaign of “Fans don’t let fans drive drunk” is in full swing.

Host with the Most

handing over your keys on Super Bowl SundayAs a Super Bowl Party host, you can be held accountable and prosecuted if someone you served is liable for a drunk-driving crash. So, the suggested tips for hosting a responsible event include:

  • Ensuring that all of your guests have sober, designated drivers in advance or be prepared to arrange alternate transportation
  • Serving plenty of food and including an assortment of  non-alcoholic/alcohol-free beverages
  • End alcohol serving at the end of the third quarter of the game and begin serving coffee and dessert
  • Taking away the keys from anyone who appears to have had too much to drink

Life of the Party

Take the necessary steps to ensure that this year’s game is not your last one. Whether going to a friend’s house or watching at a bar, you should take the necessary steps to ensure that this year’s game is not your last one.  According to an article, excessive drinking for men would be five or more drinks within a short time period (i.e. two hours) and four or more drinks for women during this same period.  Some of the precautions that you can take to avoid excessive drinking include:

  • Designating your sober driver, or planning another way to get home safely before the drinking starts
  • Avoiding binge drinking, drinks with unknown alcohol content or mixing alcohol with energy drinks
  • Eating food while drinking and alternating alcohol drinks with water
  • Asking a sober friend for a ride home, calling a cab, friend or family member to come and get you or just staying in for the night
  • Utilizing your community’s sober ride/designated driver program

Whether hosting or attending, taking the necessary steps can help your Sunday Bowl experience be a fun and safe one.

When Temptation Calls

For recent recovering alcoholics, the lure of watching the game with a few friends may seem like a harmless endeavor. However, placing yourself in an environment where alcohol is flowing freely might not be the best way to spend your day.

 

reaching for beerAccording to a publication from the National Institute on Alcohol Abuse and Alcoholism (NIAAA), approximately 90 percent of alcoholics are likely to experience one relapse over the four-year period following addiction treatment.  Super Bowl Day is associated with many of the triggers for either a slip or a relapse including exposure to large amounts of alcohol and environmental stressors. Alcohol addiction is a disease and your addictive brain is telling you that it’s okay to drink because it’s a special day. You can probably justify drinking because everyone around you is consuming.

Relapse prevention is easy to put in words, but often difficult to obtain. The simple steps include:

  • Challenge your thinking – Will I really be able to stop drinking tomorrow?
  • Reason through your relapse – What will make this time different from before?
  • Distract yourself – Maybe, I should have some more of those delicious Buffalo wings instead of a beer?

These strategies can help you resist the strong pull to drink on Super Bowl Sunday. If you are in the early stage of recovery, the easiest and most straightforward method would be to just say “no” to watching the big game in an alcohol-filled environment.

Don’t let the BIG GAME become your BIG EXCUSE!

Going to a Super Bowl party with friends or family is always enjoyable. But if alcohol consumption proves to be too much of a challenge for you then you might want to consider other options. Behavioral Health of the Palm Beaches is always here and ready to help you or your loved one maintain your sober recovery. We can tackle relapses before they can gain any ground. We will help you score those winning points toward your recovery goals. When you need that extra help crossing the goal line, call us at (888) 432-2467.

 

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Let’s Stop Overselling 12-Step Recovery

A person recently asked me to what I attribute long term recovery to. I immediately said. “Alcoholics Anonymous.” We, as professionals, or those of us who have earned admission to 12-step recovery, tend to spread the message that Alcoholics Anonymous (AA) is wonderful. We love it. You need to love it too. Are we setting people up by overselling 12-step recovery? I’ve heard patients say that we push it down people’s throats. Do we? Maybe we do. Is it really that wonderful? When a person goes to their first meeting and it doesn’t meet expectations, the experience is shallow. Maybe there’s something wrong with me? I can’t tell this to my therapist! Keep it a secret.

Some people return from their first meeting saying something like, “It’s too religious,” or “It’ a cult.”
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People Who Do Not Deserve to Have a Problem: Issues Related to High-End Care

Seaside Palm Beach opened the doors to “high-end” treatment for substance use disorders in 2009. I would like to share the experience of having been the first Director, and as a person who has maintained his involvement with Seaside to this day.

When Seaside opened it was the only substance use disorder treatment program in Florida describing itself as “high-end.” It’s possible that we were the only one on the east coast. The number of programs currently describing themselves as “high-end” has grown considerably in Palm Beach County alone.

It’s worth taking a moment to ask what exactly “high-end” care is. Although there is clearly no precise definition, adjectives used to describe this manner of care have included “executive” and “luxurious.” The term “high-end” connotes “expensive,” “wealthy,” “rich.” It may not be politically correct to openly use these adjectives, nevertheless, they exist.

Discussing the reasons for the exponential growth of high-end care is not the purpose of this article; discussing the lessons learned since 2009 is.

Seaside Palm Beach is one of four treatment facilities owned and operated by Behavioral Health of the Palm Beaches (BHOPB). BHOPB’s experience in providing quality residential care for substance use disorders dates back to 1996. In 2009 providing high-end care was new for us, but providing high-quality residential care wasn’t. Seaside was planned by people who had years of administrative and clinical experience with the provision of quality care. Even so, there were lessons to be learned along the way. Sharing knowledge acquired through experience and research with our professional community has always been an integral aspect of BHOPB’s mission.

Selecting and Preparing Staff

When staffing Seaside, we looked for the most highly qualified, credentialed, and experienced staff that we could find. We searched from within our organization and externally. It didn’t take long for us to see, and to recognize within ourselves, that we held attitudes that were negatively impacting the delivery of care.

We had staff providing services who made less money in a year than our residents made in a week or a month. In fact, residents whose income was dependent on investments sometimes had more income during their stay than the staff member did. Residents often owned homes in attractive locations around the world while a staff member may have been struggling with rent (p.s. we do pay staff well). I could go on.

Staff, who ordinarily would go the extra mile for a resident, didn’t. Negative remarks about residents could be overheard among staff. Staff whom had demonstrated remarkable empathy in the past all of a sudden became unable to demonstrate that essential quality. How could they? Residents were perceived to be people who did not deserve to have a problem.

Residents were being talked about as people who lacked “humility.” How do people with extreme wealth demonstrate humility?

Staff who had been trained to help residents look deeply into themselves, now had to look deeply into their own selves. It became obvious that residents coming from wealth had to be treated as a sub-culture (NAADAC, 2009). As F. Scott Fitzgerald allegedly remarked to Ernest Hemingway, “The rich are different than you and me.”

We needed to do cultural sensitivity training with current and perspective staff. No one can change until the need to change is recognized.

We did locate some staff who did come from wealth and made the choice to give back by helping others.

What do High-End Patients Look Like?

This may be a good time to mention that residents seeking treatment at Seaside were and are significantly older than residents at BHOPB’s other centers. The average age at Seaside is approximately forty-eight years. At BHOPB’s other facilities it ranges from early to mid-thirties. There are numerous reasons for this. The most obvious is that it often takes some time to accumulate wealth.

Seaside residents tend to be proud people. They do not respond well to confrontation, particularly when it comes from a staff member perceived to be very young. Maturity should be a sought after characteristic for on-site staff. 

Age and wealth are correlated factors. Wealth is likely to have enabled substance abusers to avoid the consequences of abuse.

It is also likely that wealthier residents have not been confronted in the workplace. They don’t get referred to management, they are management. Sometimes the wealthy substance abuser is simply too powerful to confront. Confrontation as a therapeutic tool needs to be used very carefully.

It is also likely that the Seaside resident comes from a sub-culture who could not possibly be addicted. After all, they don’t deserve to be. They feel the stigma more than any other sub-culture. “With everything you have, how could you let this happen?”

They are more likely to be referred for mental health care as opposed to care for a substance use disorder.

Want to know who else didn’t think that people from this culture could have a problem. We didn’t. I feel certain that there have been patients whom I’ve treated over the years whom I perceived to be not in need of intense services because of the privileged culture they came from. Possibly I recommended people from this culture to a lower level of care than was necessary.

We Are Products of the World We Live In

When we opened our doors in 2009 we did not expect residents coming to us who had more substance use related physical deterioration than we had previously seen. There were more frequent occurrences of high blood pressure, unstable blood sugar, impaired liver and pancreas functioning, and organicity than we had previously experienced. There were ambulatory problems, particularly among women.

Having to treat chronic pain as a co-occurring disorder was also more likely. Consequences like pancreatitis are painful. So are things like falls and neuropathy. The list is long.

Severe alcoholism often requires a longer period of withdrawal management.

Since the issues mentioned above are more likely to occur, lengths of stay for withdrawal management and treatment are likely to be longer. This was recognized by the American Society of Addiction Medicine (ASAM 2013) when their recommendations included five levels of withdrawal management.

It is important that expected lengths of stay be talked about at the outset.

As part of its pre-treatment assessment process BHOPB asks each patient, including Seaside patients, to complete the Millon Clinical Multiaxial Inventory-III (MCMI III). The resulting personality profile is used to help the therapist and the patient identify both problem areas and strengths to focus on during the course of treatment.

The initial three scales (Disclosure/Desirability/Debasement) can give the therapist some insight into how the patient presents for treatment. They are referred to as “validity” scales. Patients being treated at BHOPB represent a cross section of patients who have been presenting themselves for treatment since BHOPB’s opening in 1996. Wealth may well be represented in this randomly chosen sample of 100 patients being treated in 2010. If you look at the first three scales in Figure #1

BHOPB Patients

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You will notice that “Disclosure,” and “Debasement” are high relative to “Desirability.” A reasonable hypothesis would be that BHOPB patients are self-debasing (low self-esteem, self loathing) and are willing to tell you about it. This pattern on the “validity” scales tends to falsely elevate scores on clinical scales. In other words, BHOPB patients may not be as impaired as their personality profiles would indicate. Whatever their issues are, the issues are probably complicated by low self-esteem.

A major goal of treatment would be to increase the patient’s self-esteem. Continued low self-esteem could be counted on to be a relapse issue.

Now look at Figure # 2. For Seaside patients, “Desirability” is elevated when compared to “Disclosure” and “Debasement.” This pattern is totally opposite that seen in Figure # 1.

Seaside Patients

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This “validity scale” pattern is indicative of patients who are suppressing clinical issues. The remaining clinical scale scores will be artificially low. Therapists will have to pull teeth to get issues to work on from these patients.

This is not to say that Seaside patients are lying. They may be totally unaware of where to start.

Ironically, it’ easy for the therapist to follow them into the trap. At the end of a busy day it may seem delightful to have a patient without problems walk through the door.

Perhaps this is another argument for lengths of stay. It will take these patients a longer time just to scratch the surface.

Are “High-End” Patients More Narcissistic? If all you do is look at Figure # 2 you might conclude that they are. However, it’s probably worth stopping to think that the MCMI III was normed on a broad range of people, not just a “high-end” group of people. Are patients seeking “high-end” care using self-centeredness and grandiosity as a means of avoiding issues, or are they really that important?

These are not people who think they are God; people have been treating them that way. OK, that’s an exaggeration, but not by much.

Point is that a sense of self-centeredness and grandiosity may not be a means of avoiding issues for this population. It may be who they are.

In that case, it would not be an issue to work on.

What is Powerlessness and Unmanageability to this Group?

We’ve treated people at Seaside who have been pushed out of companies they may have started. When this occurs there’s usually a financial package, a golden parachute that goes along with the departure. Golden parachutes have ranged up to $40,000,000.

There are other times when there isn’t a severance, but the person is simply not involved in the company. Their name may remain on the door, but they are basically ignored and everyone knows it. However, the person is still receiving a very significant financial benefit.

Question becomes would a salaried therapist recognize this as powerlessness and unmanageability? A skilled, mature therapist who recognizes the downside of wealth would. It could be said that the head of a company has taken a bigger fall than a salaried person losing a job. Having spent time with a high-end population, I know this to be true.

There have been instances when relatively young people have sold companies and have looked forward to a life of leisure. They soon realize that playing golf goes only so far.

Of course people who have experienced wealth have also experienced powerlessness and unmanageability. Therapists need to be trained on where to look for it. They also have to be trained to empathize with a patient who has made more money than the therapist can imagine. This is not always possible, skilled therapists have to be selected.

Abandonment/Attachment Issues

There’s no evidence that high-end patients differ from more traditional patients seeking treatment for substance use disorders when it comes to abandonment issues/attachment issues. Having observed high-end patients for a considerable period of time I’ve come to believe that their abandonment/attachment issues are just different.

We’re used to seeing patients who have been abandoned by sexual abusers, substance abusing parents, parents who left the household, etc.

High-end patients may never have felt that they were abandoned by a parent. The parent was never available. They were brought up by a series of nannies some of whom they became attached to. Inevitably, that nanny was replaced.

As they got older it was a matter of moving from one boarding school to another.

It’s harder to identify abandonment/attachment issues when patients believe that the issues are not there. After all, everyone else they knew was brought up in a similar fashion.

So, a therapist should never conclude that abandonment/attachment issues don’t exist. Therapists need to learn where to look for them.

What Does High-End Recovery Look Like?

Traditionally, patients completing treatment for an addictive disease would be recommended to do 90 in 90: 90 12-step meetings in 90 days. It’s likely that they would be referred to a lower level of care such as intensive outpatient, and would likely be referred to a one on one therapist as well. This certainly doesn’t describe all discharge plans, but it’s close.

Sometimes there is resistance, but options are limited by financial issues, insurance coverage, ability to be given time to blend recovery and work.

Some people just don’t like the 12 step recovery process.

I know all of the arguments. I’m a person whose life has been saved by Alcoholics Anonymous (AA). However, I can understand the resistance.

We can’t push 12-step recovery down someone’s throat.

The problem is that there is no other form of support for recovery that is as available as 12-step recovery. It’s also free. “Free” is a wonderful thing, 12 step recovery is a wonderful thing, but what about people who have more options and more resources.

Some “high-end” patients might have a therapist or team of therapists available to them 24/7. Is this as good as 90 in 90? It may be, but it’s not free. In fact, it could be incredible.
I’m aware of a patient who traveled with a personal therapist and a nurse. Sober coaches and sober companions are really good sources of support.

Fact is that patients with wealth have more options than other people. I can only wish that all of these forms of support were available to everyone, but they’re not.

What happens on some occasions is that a wealthy patient is being case managed by a person who has resentments. It may be a person who is thinking “I got sober with AA, why can’t she?”

Summary and Conclusion

At Seaside, we\’re going on our 6th year of providing care to people who are frequently referred to as “high-end,” “executive” or exclusive in some way, shape or form. BHOPB’s mission has always included the sharing of experience, strength, and hope with our professional community. “High-End” programs seem to be popping up everywhere. So we are sharing what we have learned.

One thing is to pick and train staff very carefully. If a salaried staff person tells you that they don’t have resentments toward people with extreme wealth they’re either in denial or out right lying. It’s important to recognize it.

It is also important to look for staff who can relate to, or come from wealth themselves. Believe it or not they exist. Maturity should be a sort after quality when choosing staff.

High-end people come to us with patterns of denial, issues and character traits that are not all that different than our more traditional patients. They are just displayed differently and a trained therapist needs to know where to look.

The world is not fair or equitable. It\’s not the fault of the patient. It’s important to accept that people with resources may have a path to recovery that is different than those we’ve seen in the past. The objective should be to bring everyone up, not to bring a fortunate person down.

Most of all, these are people who deserve to be cared for. Addictive diseases do not discriminate. If anything, they hit a person with wealth much harder. Being able to avoid consequences is not always a good thing.

We are also treating people who are smart, creative, and often become passionate about recovery. Sometimes they are in a position to help others.

Mostly what I’ve learned, people are people.

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Embarassed man with hands covering his face

Eliminating “Shame” From Addiction Treatment and Recovery

Introspection can lead a person to look at the pluses and minuses of life. It will cause a person to look at things that have been done well and things that could have been done better. It can bring about growth through change. That is the spirit with which this is being written.

As addiction professionals, we have helped many people. Estimates are that we have helped up to 23.5 million people achieve long-term recovery. It’s hard to say exactly how many people with an active addictive disease are still out there.

In the life of an addiction professional and of a person in recovery, the topic of “shame” comes up frequently. It comes up in the treatment setting and in 12-step recovery meetings.

Often shame, or the stigma it creates, is talked about as something that is placed upon recovery by the world outside, a world or culture that we cannot control.

However, we also learn to focus on what we can control. We can control the shame that we create and we can make it go away. We can control the shame that we create and we can make it go away.

Is it surprising that we may create shame? Maybe one reason that it happens is that we are all products of the culture that we accuse of causing the stigma. We grew up in it and have been influenced by it. So maybe we have accepted shame far too easily.

It may also be helpful to remember that the recovery movement has been heavily influenced by morality, e.g. the temperance movement, religion, the Oxford Group, etc. It has only been more recently impacted by Addictions Medicine.

So maybe we are on the brink of eliminating shame from addictions treatment and recovery? First we have to look at our role in creating it. Do we have the “courage to change the things we can?”

Shame: We Didn’t Intend to Create It

The first publication created by Behavioral Health of the Palm Beaches (BHOPB)’s Research Department was an outcome study published in 2006. At that time, the Research Department consisted of two people, myself and Dr. Donald Mullaney. Though making the phone calls was painstaking and tedious, it was at times very rewarding. As a result of those phone calls a few people got back into treatment and got back on track.

We did the best we could. We had to trust in people’s honesty. It was often hard to track people down. The result was that, our best efforts indicated that 63% of the people remained substance free one year after leaving residential care at BHOPB. We did an honest job. A 63% percent success rate seemed reasonable. We were pleased with ourselves.

We never really paid attention to the finding that 37% of the patients we contacted were labeled ‘failures.’ You were either a ‘success’ or a ‘failure.’ There was nothing in between. After all, it was a study designed to determine our ‘success rate.’

Creating ‘treatment failure’ led me to start thinking about and paying attention to other ways that we may have unintentionally created shame. Unfortunately, I found a few.

We’ve all heard patients say, “I’ve been to treatment before.” Are they saying that they’ve failed before? It has to feel bad. It has to feel shameful. I wonder what it feels like to say “I’ve been to treatment three times before.”

It makes me feel worse when I think about how many times I’ve asked a patient: “How many times have you been in treatment?” What am I really asking? The implication is: “How many times have you failed?”

Shame or the expectation of judgment will keep a person from returning for help if a relapse occurs. We may deny that this happens, but take a look at treatment plans for all patients who have returned to treatment multiple times. There’s always another First Step and the telling of a story. There’s the assumption that a person who has relapsed didn’t get the First Step. Where in the First Step does it say anything about not drinking?

A person who had established a period of recovery is not the same as a newbie. A person who has experienced recovery has learned a thing or two. It’s likely that a return to social drinking didn’t work. That could be a lesson the newbie has yet to learn. A person coming back likely knows something about 12-step recovery or maybe they know that trying to stay sober without support is really difficult. These are valuable lessons.

The Language of Shame

We tell our patients that they have a chronic disease but we use acute care models. Acute care language has become the language of shame.

We convey the message that you better get well fast and in the way we want you to do it or we don\’t want anything to do with you. We have made statements like: “Come back when you’re ready” or “You need to do more research.”

I hate to admit that I have made similar statements to patients. What was I thinking? Would any one of us have made such a statement to a person with any other disorder? Similarly, I’ve often heard the expression, “I”m not going to work harder on your recovery than you are.”

On the other hand, we generally expect a patient to be in denial and ambivalent about recovery. So we expect a patient who is in denial of their disease and probably doesn’t really want to be in treatment in the first to work hard? We can’t have it both ways.

Traditionally, we’ve relied on one particular therapeutic skill to pull a patient out of their denial: confrontation. So if the patient is not shamed enough by this time we yell at them. That may be an overstatement, but not always.

How Do We Fix It?

Neither SAMHSA (2012) nor the American Society of Addiction Medicine (2013) includes abstinence from substance use as a measure of recovery. ASAM defines recovery as “A process of sustained action…in the direction of consistent pursuit of abstinence.” So, as long as a patient is still seeking abstinence they’re still in the game. Why wouldn’t they be? Diabetics with unstable blood sugar levels, but still in pursuit of stability, are never considered to be treatment failures. Only we do that!

If perfect blood sugar was the criteria for the successful treatment of diabetes, almost every diabetic being treated would be a “failure.” A similar argument could be made for the successful treatment of hypertension. Diabetics and people with hypertension are not considered to be “failures” as long as they’re treating their disease. Why not do the same for people with an addictive disease? It doesn’t have to be all or none; success or failure.

How Do We Measure Sustained Action in the Direction of Consistent Pursuit of Abstinence?

I think that the answer has to do with keeping people engaged in the process of getting well. We tell patients that we’re treating a chronic disease, but, traditionally, treatment has been heavily loaded on the front end.

We can learn something from how other chronic diseases are treated. Diabetics and people with hypertension will be monitored for their entire life. Can addicts have recovery check-ups with an addictionologist? Check-ups could be quarterly or semi-annual, but it would keep addicts engaged in treatment. There wouldn’t be failures.
There is something to be said for helping people in their “consistent pursuit of abstinence.”

The Term “Outcome” Is Inappropriate

If we’re treating a chronic disease, we’re not measuring an “outcome.” We’re measuring progress at a given point in time.

What a person has learned in the consistent pursuit of abstinence is important and needs to be taken into account when a patient with a history in recovery re-engages into a higher level of care (assuming that we consider that a patient has been engaged in a lifetime process).

It is true that within 12-step recovery a patient would be encouraged to pick up another white chip signifying that the recovery process has begun again. Even within 12-step circles picking up another white chip has been referred to as “the walk of shame.”

It is up to us to encourage a person to perceive it as a “welcome back” gesture.

We need to get better and take responsibility for motivating our patients. We don’t throw people away. Another way that we tell people that we don’t want anything to do with them and create shame is through statements like “come back when you’re ready” or “you need to do more research.” As professionals, motivating patients is our responsibility.

We can get better at motivating our patients and it is important that we do. We can learn to use Motivational Interviewing and Motivational Enhancement to help the people we work with.

What we would never consider doing with other disorders, we should not do with addictive diseases either.

The therapeutic skills of addiction Professionals have vastly improved from the days in which confrontation was the most frequently used counseling tool. Let’s remember that treatment for addicts began by one person helping another. The people providing care were well intentioned but untrained. Today therapists are mostly people with Master’s degrees and have been well trained in the use of therapeutic skills.

It is important to remember, shamed or not, a lot of addicts/alcoholics have gotten well because of devoted, well-intentioned people. We\’re just trying to get better.

As a reader you may not agree with every point, but I think that it\’s hard to disagree with them all.

It also seems possible to argue that developing a sense of humility is important in the process of recovery. The line between shame and humility seems pretty blurry. Concepts like “powerlessness,” “unmanageability,” and “sanity” may be close to that line. Care needs to be taken when they are introduced.

It Is Also Important to Remember that 12-step Recovery Is to be Respected

We may have to teach patients how to cope with aspects of 12-step recovery that may not be working for them, but there is no support out there that approaches what 12-step recovery can do and has done.

I believe that the major reason to turn away from 12-step recovery is arrogance. People who were never able to manage their addictive disease before treatment somehow think that they can do it now.

People can live with whatever they disagree with. I don’t know of any alcoholic who did a religious survey of bar patrons before drinking with them.

Being Respectful is Part of Recovery

I’ve tried introducing myself at 12-step meetings by saying, “My name is Michael, I’m in Recovery.” Much to my surprise no one blinked and eyelash and I was not the only one using that or a similar means of introduction.

I know that there are some people who find any change to 12-step recovery sacrilege. The fact is that 12-step recovery does change as culture changes. It would be silly not to and no one has ever accused 12-step recovery of being silly. Forty years ago no one heard, “My name is ___, I’m an alcoholic and addict.” Like it or not, it happens today.

Change Happens When It Works

It’s going to take a while before addiction is uniformly treated as the chronic disease that it is. Treatment for addiction needs to become more similar to the treatment of other chronic diseases which recognizes that each disease has its individual characteristics. The intensity of care needs to match the intensity of the symptoms. There should never be a time when an addict is not getting at least periodic recovery check-ups.

The chronic care model works.

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