Chapter 1:

The Missing Elements

Fifty to 90 percent of alcoholics and addicts relapse in the first year after treatment. In the face of such grim figures, it’s easy to toss around blame. Treatment doesn’t work. The addict isn’t doing what she should. Doctors are the new drug pushers. But the truth lies elsewhere for the most part and requires a new conversation.

Relapse is caused by underestimating what it takes to stay sober. Addicts, their families, and society commonly minimize what is required for successful recovery. Addicts can’t simply think their way out of addiction. Recovery requires action. It’s much more than leaving the drug behind, whether that drug is alcohol, cocaine, marijuana, heroin, methamphetamine, pain medications, or tranquilizers. Recovery is about changing behaviors, which leads to changes in thinking. It’s about positive spirituality—honesty and willingness and letting go of resentments. It’s about taking a fearless look at one’s self and the wrongs of the past. It’s about cleaning house and making amends. Recovery is about more than abstinence; it’s about becoming the kind of person who can engage in healthy relationships.

Abstinent without recovery, the addicted person is haunted by the past, suffers in the present, and can’t see a promising future. The control centers in the brain are being depleted by the constant internal battle not to pick up a drink or a drug. Relationships with family are frayed and get- ting no better. For these addicts, relapse is usually just a matter of time.

An old adage says it best: “When a heavy drinker stops drinking, he feels better. When an alcoholic stops drinking, he feels worse.” For alcoholics and addicts to begin enjoying life again, they need to work a rigorous Twelve Step program of recovery in groups such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). These programs work because they treat the chronic nature of addiction that affects the mind, body, and spirit. There is no cure, only a daily reprieve that requires ongoing management. If we don’t understand this basic tenet of success, we don’t understand recovery.

When we believe treatment centers are the heart of recovery, we base our hopes and dreams on a flawed assumption. Treatment isn’t recovery, and clinical teams don’t know who will stay sober and who won’t. Stellar patients drink on the flight home, and seemingly hopeless cases never drink again. Treatment staff know what works, but no one knows who will follow directions and do what it takes to stay sober.

Recovery doesn’t officially begin until treatment ends. It isn’t dished out by doctors or teased out by therapists. It happens in a community— and not just any community. It requires working a Twelve Step recovery program with other alcoholics and addicts. Recovery requires broad changes in how addicts live their lives, the kind of changes that would be tough work for anyone. Our loved ones are attempting it with a brain so compromised by addiction that their brain scans look like Swiss cheese. With decision-making abilities impaired and emotions turbulent, it’s no wonder so many don’t get very far before they crumble and relapse.

The purpose of treatment is specific. It is designed to attend to the acute stage of this chronic illness. Involvement with patients is relatively short. A team of professionals tends to the most intense and severe symptoms, most notably the physical and emotional discomfort that comes with early abstinence. And many do an excellent job of it. But the scorecard we use to rate the success or failure of these facilities erroneously holds them responsible for patients’ sobriety once they return home. Addiction is a chronic disease, and it must be managed by working a daily Twelve Step program. Treatment centers can only prepare patients to follow through with ongoing recovery recommendations. They can’t do it for them. If addicts don’t follow the directions for ongoing recovery, they are at high risk for relapse.
While not making direct promises of keeping people sober long term, with some notable exceptions, treatment centers do so implicitly. Instead, professionals need to be straightforward about what they can do, why it is important, and what they can’t do.

This is exceedingly important because today we have so many treatment centers popping up across the country, trying out new strategies and protocols that might differentiate them from the pack but aren’t necessarily effective if our goal is sobriety. This makes it difficult for families to evaluate treatment options. It’s hard to be a smart consumer in a confusing arena.

The problem begins with the rubrics we’re using—our scoring guide to evaluate the quality of treatment—which are flawed. Treatment can- not be responsible for recovery outside the treatment program. It can only be held responsible for its effectiveness in these areas:

1. Medically detoxing and stabilizing patients, thoroughly assessing their needs, and setting treatment goals
2. Working with patients to break through denial at the deepest possible level, in a respectful and dignified manner, so they accept that they have a chronic disease that requires lifelong abstinence
3. Integrating the Twelve Steps into the treatment plan (Twelve Step Facilitation has been shown to be most effective)
4. Providing patients a recovery management plan that includes relapse prevention strategies and a clear understanding of how to work a Twelve Step recovery program when returning home (encouraging the patient to go to AA or NA meetings while in treatment and connecting the patient to a recovering person in his home area help accomplish this goal)
5. Inviting the family to attend the family program and encouraging children to attend a children’s program if one is available
6. Developing aftercare recommendations designed to give an appropriate level of support that will increase the likelihood that patients will engage in recovery once they leave treatment
7. Engaging the family in the entire process, as appropriate

There is also much talk about evidence-based treatment, but even though intentions are good, there are problems. Evidence-based doesn’t necessarily mean the research is flawless, nor does it mean it is measuring the same outcome we are aiming for: lasting sobriety. Results depend on the quality of the research, the validity of the testing, replication over time by impartial researchers, and reviews by other researchers. Research bias—particularly the bias of what is actually published (mainly the positive results)—can lead to “proving” something is true when it is not true. Instead, we should be talking about “levels of evidence” and “quality of evidence.”

According to Eric Topol, MD, cardiologist, geneticist, and re- searcher from the Cleveland Clinic, in his book The Creative Destruction of Medicine, “Consumers, unfortunately, are typically getting data from small, observational studies, published in obscure journals or not at all, in which there is no real control group or no randomization, and shaky end points.” He goes on to say that even very large-scale observational studies have produced faulty results, misleading the public more than once. Professionals can be misled too.
Dr. Topol has coined the word litteature, denoting that too much of the research is “littered with misleading and false-positive findings.” We must be smart consumers of research, he says. “I don’t want to be excessively negative, but the right assumption in reviewing any new data presented to consumers is to question it . . . consider the new finding null and void unless you are thoroughly convinced that the evidence is compelling.” He is speaking of medical science, but results in the field of addiction and behavioral health are even more tenuous.

Misconceptions about treatment, leading to false expectations, coupled with the frustration of relapse, have families throwing up their hands and proclaiming, “Enough! Treatment doesn’t work!” Once they
reach this verdict, hopelessness can settle in, and the only question left is “Now what?”

What if I told you there was a group of addicted people who almost never relapse in the years following treatment? As a matter of fact, 78 percent never have a single relapse. Less than 15 percent have one re- lapse but not a second. And those with more than one relapse? A whopping 7 percent. Not only that, these folks are some of the most difficult addicts to treat. When I worked in inpatient treatment, having them as- signed to our caseload would elicit groans of despair because we knew our work just doubled. “They’re the worst patients!”

The alcoholics and addicts in this group are getting something other addicted loved ones aren’t—a team who works with them for five years after treatment to make sure they build a solid program of recovery and make the prerequisite changes that lead to lasting sobriety. Because when alcoholics and addicts are left to their own devices—in spite of the universal cry that they can do it on their own—the odds are they’ll be drinking and drugging again.

Author Stephen King, in his column for Entertainment Weekly, writes about just this point.
[Managing] good sobriety without much help . . . is a trick very few druggies and alcoholics can manage. I know, be- cause I’m both. Substance abusers lie about everything and usually do an awesome job of it. I once knew a coke- head who convinced his girlfriend the smell of freebase was mold in the plastic shower curtain of their apart- ment’s bathroom. She believed him, he said, for five years (although he was probably lying about that, it was probably only three). . . . Go to one of those church-basement meet- ings where they drink coffee and talk about the Twelve Steps and you can hear similar stories on any night, and that’s why the founders of this group emphasized complete honesty . . . what happened, what changed, what it’s like now. . . . If my own career as a drunk both active and sober has convinced me of anything, it’s convinced me of this: Addictive personalities do not prosper on their own. Without unvarnished, tough-love, truth-telling from their own kind—the voices that say, “You’re lying about that, Freckles”—the addict has a tendency to fall back to his old ways.

The problem is, of course, that most alcoholics and addicts coming out of treatment don’t want to work a program of recovery that requires taking action. They’re convinced they have changed, with surprisingly little effort and in a remarkably short amount of time, and they often convince their poor gullible families of the same. These alcoholics and addicts think they have a better idea, which usually entails staying sober on their own with an easier, softer approach—one that eventually lands them back in the liquor store or crack house or doctor’s office looking for a scrip. They do this not because they are bad but because this is the way the disease directs their thinking processes.

This lack of compliance is repeatedly used by professionals and researchers as the reason AA or other Twelve Step programs don’t work. Confusing an addict’s compliance with a program’s effectiveness is faulty analysis. The real question is how do we increase compliance?

It isn’t that Twelve Step programs don’t work. It is that alcoholics and addicts, for a complex set of reasons, have difficulty adhering to anything in a consistent manner. Consider the struggles diabetics have trying to comply with their recovery programs—and they do not have to contend with the cognitive impairment we see in addicts. Research shows that among patients who only needed to take a medication to treat their illness, a mere 50 percent complied. Nobody would argue that medications don’t work because people don’t take them as directed. When it comes to addiction, the sustained commitment it takes to recover is in another stratosphere from swallowing a pill.

What if we, as families, could initiate a program with our loved ones that models those used by the recovery winners mentioned above? What if we could provide the missing element—the one that makes it much tougher to relapse? Once we appropriately identify the staff in treatment centers as the “first responders” instead of the sole providers of a stand- alone solution, our expectations of treatment change. Without a doubt, treatment has a vital job to do, but it’s only the beginning. Treatment centers can keep our alcoholics and addicts only so long, and then they come home to us. This is when it takes all of us bonding together for recovery. If we’re to take our place among the winners, it most definitely takes a family.

Families and close friends have a tremendous amount of influence in an addict’s life, but we usually don’t know it. Too often families believe they are powerless. They don’t understand their power and often feel mistreated, disregarded—even disliked.
The very people an alcoholic or addict needs most are the people he often fights against. He tries to appease family, only to break the promises he makes to them. Or he ignores those closest to him, pretending he simply doesn’t care. The addiction not only punishes the people the addict cares about most, but it abuses him too. The addict breaks promises to himself. He pretends none of the pain matters. And, even as he begins losing everything he holds dear, he can’t stop this downward spiral. He is typically filled with shame as he strikes out in anger. He doesn’t understand what is happening inside himself. That is what it’s like to live under the tyranny of addiction. It doesn’t have to be like this. A rigorous recovery program can reverse the insanity of this disease, making things better one day at a time.

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Introduction: We Come Home Together