Having worked in the addiction treatment field for over 25 years I recognize the importance of abstinence for quality long-term recovery. However, when it comes to helping someone transition from addictive use to total abstinence, it’s not normally that simple.
Sometimes a transitional harm reduction approach is necessary to help the person with an addictive disorder to get and stay sober. I am not talking about controlled drinking/using, which received a lot of press during the 1990’s. That didn’t work. What I am talking about is a developmental process of shifting from active addiction to total abstinence using a step-by-step transitional approach.
In order for a person to even want to attempt sobriety, they need to see why it is in their best interest to do so. I’ve seen people “pushed” into abstinence by a judge, their spouse, their job, etc. I also know that if that is the only reason they stop drinking/using they will usually start up again as soon as they believe they can “get away with it.” However, that first push can be used as a motivational intervention, if it is backed up with a strategic developmental approach.
The first step is to help the person examine both the benefits and consequences of their addictive use. This process often leads to strong resistance and denial. It’s important to remember that denial is not a pathological condition but a coping tool that worked in the beginning and eventually resulted in problems and negative consequences.
A compassionate non-judgmental approach is important to work through (or around) this resistance and denial—Motivational Interviewing practitioners often call this “rolling with denial.”I have found the following four questions to be very helpful in allowing people to explore the payoffs and consequences of their substance use.
- What is the best thing I can expect if I continue to drink/use the way I do now?
- What is the worst thing I can expect if I continue to drink/use the way I do now?
- What is the worst thing that can happen if I decide to be in recovery?
- What is the best thing that can happen if I decide to be in recovery?
Each question is designed to start the person thinking about their substance use in a different way. Since it is important to discover what the payoffs are for drinking and/or using, the first question is crucial. Their reasons should be validated. Later on in the developmental process the person can learn new recovery-prone ways to get those payoffs.
The second question allows the person to explore how alcohol/drug use could lead to negative consequences that they would rather avoid. This question often brings up strong denial, which is a normal response when someone feels threatened. Too often denial is seen as a “Bad” thing, but in reality denial is just a defense mechanism that can be overcome by education and respect.
The purpose of the third question—which is the most important—is to examine the person’s fears about coping with life without their old tools. Many times people have no clue about what recovery really is. They may see recovery as deprivation and suffering. If recovery was all about that, I sure wouldn’t want any part of it myself. Again, the answer to this question determines what the person really understands about recovery, and gives a starting place for the educational process.
For decades research has shown that human beings respond much more favorably when offered rewards, than they do when threatened with punishment. The purpose of the fourth question is to educate the person about why recovery is in their best interest—what is the payoff! I often add one final question—what do you think is the most likely thing that will happen if you continue drinking/using the way you were when you got into trouble? This is a reality check for them.
If the above questions are processed appropriately, the addicted person will be ready to start the transition from active addiction to healthy recovery. However, it is unrealistic to believe that everyone will stop and never drink/use again. What usually occurs is a testing out period. When the person finally realizes that all these testing and control strategies don’t work, they are ready for the next developmental stage, which is stabilization.
Stabilization is the stage where the person faces life knowing that alcohol/drugs are no longer a good option. There is a grieving process that occurs. One of the major tasks of this stage is for the person to learn how to cope with stress and to manage urges and cravings. Many people experience setbacks during this stage because recovery is a biopsychosocial process, which includes brain chemistry changes that need to be healed. Even the most motivated and determined person may give into urges and cravings. This occurs when the brain dysfunction kicks in and they are no longer able to think rationally. At this point social support becomes very important.
The next stage of the developmental process is early recovery. There are four prerequisites that I look for when evaluating whether or not someone really is in early recovery.
- Does the person admit and accept that they are chemically dependent?
- Does the person have a belief and hope that recovery is possible and even preferable to using?
- Is the person actively performing the footwork (behavioral changes) in the biopsychosocial areas that recovery requires?
- Has the person been able to remain abstinent for 60 to 90 days?
If the answers to all of these questions are satisfactory, then I determine that the person has moved into the early recovery stage. Remember sometimes people can and do relapse even after moving into long-term recovery. The good news is that with an effective relapse prevention plan in place they can lower the risk of relapse, and if they do relapse they can move back into recovery sooner.
Total abstinence is the final goal for recovery—not the first goal. The formula for a successful recovery requires a developmental approach that uses a motivational hook, exploration of the pros and cons of chemical use, education about non-chemical coping tools, supports a commitment to abstinence, and follows a biopsychosocial recovery plan. In the beginning it is essential to remember an important self-help program slogan “progress not perfection.”