Every treatment facility has them. Every practitioner is confronted by them. Every administrative staff asks, “Why can’t we prevent them or stop them?” What are they? The dreaded AMA—a client wanting to leave treatment for a myriad of excuses that we identify as “against medical advice.”

Line of Prevention

Tip #1: Prevention of the AMA at initial contact. Prevention of AMAs starts with the very first contact with your facility—usually the Intake Department. The initial phone call should be informative, clear and honest. This is not the time to make promises to the potential client just to “fill the bed” or “get them in the door.” Your facility’s intake department should be well-educated on: the treatment program; rules/policies; acceptable insurance plans; financial terms or agreements; and screening of appropriateness of clients for the facility. Any concerns or questions beyond the scope of the intake department staff’s knowledge should be referred to the appropriately designated staff.

It all begins with one experience shared by the overwhelming majority of alcoholics and addicts who have tried to abstain—picking up the first drink/drug of relapse with an expletive of frustration and/or despair, most commonly starting with the letter “f.”  

Sometimes an effective intervention is developed from nothing more than reviewing an old technique and its components. I cannot remember the first time I was told to “list the pros and cons” when facing a decision. Treatment professionals, mutual support people (i.e. 12 Step sponsors), parents, spouses and just about anyone who has ever been given the advice themselves has passed this pearl on to ­others.

What is overlooked with this sage bit of wisdom is a natural predisposition against making changes. I have found this to be especially prevalent when working with individuals afflicted with addictions. Fears of failure, fears of success, lack of self confidence and a negative self image are just a few of the reasons given for the inertia. Usually, a long list of reasons for making a change cannot overcome these internal roadblocks. Often, even when I reach an agreement with the client that the change is necessary, and that the proposed solution to the problem is sound, I find in the follow-up sessions that inertia has taken over and that no action has been taken.

Generally, clients offer very little in the way of plausible reasons for not taking action. They readily acknowledge that the change is needed, that the course is a reasonable one, and that their situation would be improved by making the change. Conversely, they were able to articulate well the negative consequences of not making the change. What was not being adequately explored was either the payoff for not making the changes or the perceived negative outcomes from making the changes. When this became evident, I ex­plored ways to incorporate these two elements into the decision making process.

The result is what I call the Four Quadrant Problem Solving Aid, or the Four Quadrant Decision Making Aid. Either moniker describes the process. I have revised the old method of drawing a line down the middle of the paper to separate the pros and cons by having the client draw an additional line. The aforementioned vertical line is supplemented with a horizontal line to divide the paper into quadrants.
In the upper left quadrant I instruct the client to list all of the anticipated positive outcomes for taking the proposed action on the issue being considered. The upper right quadrant is for the anticipated negative outcomes taking the action. The lower left quadrant is for the anticipated positive outcomes for NOT taking the proposed action on the issue being considered. Finally, the lower right quadrant is for the anticipated negative consequences for NOT taking the action. I usually will work through one or more of these with the client.
Actively addressing considerations for not taking the proposed action accomplishes two important factors. First, it acknowledges that they exist. As simple as this sounds, we often miss the mark by calling this inertia denial, defensiveness or resistance; and ignore its significance in the transition from decision to action. Second, by identifying a client’s reluctance to take action, it is easier to identify, address valid concerns and separate them from frivolous excuses.

Four Quadrant case study
An example of the technique in action, along with the results, may help to illustrate the application of this intervention. I had a client whose daughter was in residential substance abuse/behavior modification treatment. The daughter’s primary counselor wanted to start joint counseling sessions. My client was struggling with this decision as her daughter’s perceived behavior was continuing to be manipulative and deceitful, and she felt that her daughter’s manipulation was being effective and that the treatment staff believed her. Past visits had left her feeling that the staff was working against her and “siding” with the daughter. After brainstorming the four quadrants, there were two quadrants that held a clear majority of the items. One was the anticipated negative results of taking the action. The other was the anticipated positive results for not taking the action. Further processing of the entire list shifted some of the items to create an even further imbalance. When she was able to see the results in front of her, she decided not engage in joint counseling. The decision and reasoning behind it were respected by her daughter’s counselor, who made no attempt to pressure my client to change her mind. Later, the same client reported to me that she had utilized the Four Quadrant technique in her decision-making process when offered a promotion and major change of job responsibilities at her place of employment.
For this client, the considerations for not taking the action were at least as important as the considerations for taking the action. By acknowledging and processing the considerations for not taking the action, she was able to make an informed decision which she was able to translate into action; which in this case was to decline to make the change. As a result of her previous utilization of the technique, she decided to replicate the technique for assistance in her decision-making concerning her employment. She decided to take the action and accept the promotion/job change. In both of these situations, understanding the reasoning behind why she was taking, or declining to take the action, was instrumental in translating the decision into action.

This speaks to another consideration. Many of our clients have difficulties with self-confidence, and often will not take action due to not believing they are capable of taking action they know is ultimately in their best interest to take. Having their fears on paper assists them in overcoming them. One client was struggling with relationship issues. The relationship had started while both were in active addiction and now that she and her partner were in early recovery she was filled with self doubt about her feelings and his. She was given the assignment of completing the technique. During the next session, she processed how she was able to see that most of her fears were groundless. She was then able to make a renewed commitment to the ­relationship.

Now, let’s put the technique into practical application. You are my client and I am going to assist in deciding if the technique will benefit your practice or not. First we construct and label the quadrants. When completed it looks like this:
 • Anticipated positive outcomes utilizing this technique with my clients
• Anticipated negative outcomes utilizing this technique with my clients
• Anticipated positive outcomes from not utilizing this technique with my client
• Anticipated negative outcomes from not utilizing this technique with my client

Next, brainstorming outcomes and placing them in the appropriate quadrant is assigned as homework. Finally, we process the completed quadrant chart. Since I am not available to help with the processing, you will have to determine for yourself if this technique is worth trying with your clients. I have found that it has beneficial for my clients, I hope you will also.

Robert Proehl, CADC provides substance abuse and anger management counseling to clients at Gateway to Prevention and Recovery in Shawnee, Oklahoma. He has worked in the field of substance abuse counseling for over 12 years and is currently enrolled in a Master’s program in counseling. He can be contacted at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

The Substance Abuse and Mental Health Services Administration (SAMHSA) estimates nearly 2 million Americans abused or were dependent upon opioids in 2007 (OSA, 2009). Recently, the availability and abuse of illicit opioidi drugs (heroin, morphine, opium) as well as the non-medical use of opioid medications (fentanyl,  morphine, oxycodone) without prescription have considerably increased in the general population, causing profound negative consequences as well as significant challenges within behavioral healthcare. The prevalence of opioid use disorders and opioid- related admissions into addiction treatment ­settings are on the rise, with more Americans needing, seeking and receiving treatment for opioid-related problems than ever before. However, individuals still commonly find it difficult to access needed treatment services due to factors, such as limited treatment capacity in their region; insufficient insurance coverage/program cost; lack of awareness and bias of providers; and social stigma/discrimination related to addiction.

Optimistically, major improvements have been made around how treatment of opioid use disorders is being delivered, while new medications and treatment protocols (office-based buprenor- phine treatment) have facilitated a huge increase in treatment capacity. This article—the second is a series focusing on medication assisted recovery—presents a concise overview of medication assisted treatment (MAT) of opioid use disorders and opioid pharmacotherapy options currently available in the United States.

Opioid use disorders
Opioid use disorders (OUD) include: opioid use (abuse and dependence; addiction); opioid-induced (intoxication and withdrawal); and opioid-related disorders. These disorders are generally considered high severity conditions which typically require long-term treatment, ongoing monitoring and multiple treatment episodes (CSAT, 2004; 2005; 2006). Globally, consensus now exists that opioid addictionii is a medical disorder which responds effectively to treatment when counseling/behavioral therapy and opioid pharmacotherapy are combined to promote recovery. This is not to suggest the role of psychological, spiritual and social factors are not critically important in recovery planning as much as it is a refutation of the antiquated notion that opioid addiction is a moral defect/character flaw best responded to as a criminal matter (CSAT, 2005; 2006).

For many with OUDs, repeated use of opioids (four to six times per day) is motivated almost entirely by the intense desire to avoid withdrawal symptoms (nausea, vomiting, diarrhea, anxiety, physical pain and insomnia) which occur within hours of the last opioid use. Most individuals become trapped in a constant cycle of opioid use/withdrawal which creates an endless loop that consumes most of the person’s energy, attention and activities. Although many with OUDs will openly admit that they initially used opioids to get “high,” most report the primary objective quickly becomes avoidance of opioid withdrawal. Count­less people in recovery have shared that personal choice to use opioids is quickly replaced by the necessity to get “normal” or avoid withdrawal.

The recovery process for many individuals with OUDs is complicated by comorbid medical issues such as HIV and hepatitis; co-occurring mental disorders; stigma and discrimination; and considerable economic, social and legal challenges. However, research clearly demonstrates that many can and do recover from these debilitating disorders when they receive indi­vidualized recovery support services and effective integrated treatment which includes pharmacotherapy and ­counseling.

Pharmacotherapy
Determining the appropriate pharmacotherapy treatment option for a person is a complex process based upon numerous factors, as all MAT options have benefits and challenges. The selection of MAT options for each person should be a collaborative process between family members, significant others, medical and addiction professionals knowledgeable of MAT and others interested in promoting the recovery of the individual.
Currently, three medications are used widely in the treatment of OUDs as maintenance medications: metha- done, buprenorphine and the combined buprenorphine formulation which includes Naloxone. (Table 1 lists these, as well as some of the medications used in detoxification programs to treat OUD symptoms.)

Methadone: Viewed as the “gold standard,” methadone is a full opioid agonist that assists individuals reduce opioid cravings and withdrawal as well as block further opioid effects. Methadone is one of the most widely available, inexpensive and effective treatment options available. Strictly regulated, it may be dispensed for the treatment of addiction only in approved opioid treatment programs (OTP).

Buprenorphine: Approved in 2002, buprenorphine is a partial opioid agonist medication with similar benefits as methadone. Unlike methadone, bu-prenorphine can be dispensed by prescription from federally approved physicians and does not require individuals be treated in OTPs. Buprenorphine has a “ceiling effect” which reduces the misuse potential of the medication. Now widely available across the United States, buprenorphine can be a costly, yet effective treatment option that has assisted many in their recovery.

Buprenorphine and Naloxone: Like buprenorphine, this medication is taken sublingually and combined with Naloxone to further reduce diversion potential. Research indicates the bu- prenorphine medications may be equally effective in treating OUDs as methadone.

Naltrexone: An opioid antagonist medication with no narcotic properties, naltrexone is typically used as an aversive treatment since it immediately produces opioid withdrawal if opioids are ingested. In some cases it is used to induce withdrawal to determine if an individual has OUDs.
Clonidine: Frequently used to treat OUDs withdrawal symptoms, clonidine is viewed as superior to methadone for detoxification purposes since it provides no opioid effects and can be dispensed without special program licenses and with fewer complications (CSAT, 2006).

Marshall Rosier, MS, CAC, LADC, MATS, CDP-D is the Executive Director of the Connecticut Certification Board (www.ctcertboard.org) and is a published author, consultant and lecturer specializing in medication assisted recovery and co-occurring substance use and mental disorders. Marshall obtained his graduate degree from Yale University and over the last 20 years has worked in diverse academic and treatment settings.

References
CSAT (2004). Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) 04-3939. Rockville, MD: (SAMHSA).
CSAT (2005). Medication-assisted treatment for opioid addiction in opioid treatment programs. Treatment Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA) 06–4214. Rockville, MD: (SAMHSA).
CSAT (2006). Detoxification and substance abuse treatment. Treatment Improvement Protocol (TIP) Series 45. DHHS Publication No. (SMA) 06–4131. Rockville, MD: (SAMHSA).
OAS (2009). Results from the 2008 National Survey on Drug Abuse and Health: National findings. HHS Publication No. (SMA) 09-4434. Rockville, MD: Office of Applied Studies (SAMHSA).
(i) Many use the term opioid and opiate interchangeably. However, opioid refers to all opiates/opioids whereas the term opiate is meant to refer only to the natural derivatives of the poppy/opium plant (ii) The term opioid addiction is commonly used to refer to opioid dependence

Recovery involves making the most of a life that has been rescued from addiction (Kinney, 2002). A primary goal of long-term recovery is learning to have healthy relationships. For chemically dependent men, establishing and repairing relationships with their children is a major recovery task (Kinney, 2002; Fals-Stewart, 2002; Larson, 1985).

Children and adolescents are greatly impacted by their fathers’ substance use. Their use increases the risk that daughters will experience depression, academic decline, trauma, promiscuity, pregnancy and substance abuse. Sons of fathers with substance use disorders become vulnerable to destructive peer group affiliation, delinquency, crime, emotional distress, academic decline and substance abuse (McMahon, et al, 2008 & 2002; Mayeda, S. & Sanders, M., 2008; Cooke, et al, 2004; Haughland, 2003; Broooke et al, 2003; Fals-Stewart et al., 2003; Parke, 2002).

The challenge
As alcohol and drug use increases, chemically dependent fathers’ relationships, including those with their children, suffer, as his primary focus is on using. In early recovery, his focus then shifts to repairing relationships that have been damaged during addiction, including father/child relationships (Kinney, 2002).

There are many core issues for chemically dependent men that make parenting a challenge, even in recovery, including:
• Father hunger—Many were abandoned by their fathers, increasing the likelihood that they will abandon their children. Heavy substance use is one method of covering the pain caused by early childhood aban-don­ment (Mayeda & Sanders, 2007).
• Father wounds—Many have also experienced injury at the hands of their fathers, ranging from physical abuse to verbal abuse to sexual abuse. Left unaddressed, this abuse in­creases the chances that they will injure their children (Mayeda & Sanders, 2007; Bly, 2004).
• Male depression—A unique type of depression, identified by Terrence Rule as “male depression,” is attributed to early childhood abandonment by fathers, and is almost always present in addicted men. This depression is often undiagnosed because of the many masks that disguise it, since many men who are depressed do not look classically depressed. These “masks of depression” ultimately affect parenting.

• These masks include a continuum of anger, rage and violence. Male socialization often does not give males permission to express vulnerable emotions such as sadness and hurt, which are very normal emotions for males who are abandoned by their fathers. They are taught to internalize these emotions, which often later emerge in the form of anger. Rage is the end result of anger that has built up after extended periods of time. Violence may be the offshoot of repressed rage; and children may be targets of this anger, rage and ­violence.
• Another mask of male depression is the tendency to push others toward perfection. This occurs because the physical drain of depression renders the father unable to fulfill household duties. To his children, he appears angry, not depressed. As he continues to burden the children, they suffer from feelings of inadequacy and anger. Secretly, he may have feelings of failure as a man, spouse, partner and parent. This feeling of failure can lead to increased feelings of depression, resulting in isolation from others, including his kids.  There are many men who respond to these feelings of depression and failure by engaging in numbing behaviors, which may include heavy substance use or substituting substance use with process addictions (i.e., compulsive gambling, overeating, cyberspace addiction and multiple affairs). These behaviors may create more distance between them and their children (Real, 1997).
• Limited role models—Many chemically dependent men report having limited role models for learning to bond appropriately with their children. This makes it difficult to know how to be a sensitive and caring father in recovery. Since many of these men have not experienced bonding with their own fathers, it is often difficult for them to form intimate bonds with their own children (Bly, 2004).

The good news
When fathers recover, their children can improve emotionally, psychologically and academically (Fals-Stewart, 2002; Lowinson et al, 2005). Addi­tion­ally, these children may also become less anxious and depressed and more optimistic (Lowinson et al, 2005). There is evidence that medical problems among adolescents and children diminish as a result of parental recovery (Kinney, 2002). Below is a list of suggestions that counselors can use to help men in recovery build and repair relationships with their children.
• Encourage fathers to seek support from other fathers in recovery (Lowinson et al, 2005). The 12 Step literature suggests that the therapeutic value of one addict helping another is unparalleled. This may also be true in building relationships with their children. Part of the wisdom of
12 Step programming is that it requires a person to take recovery one step at a time. This is solid advice for fathers wanting to rebuild relationships that have been damaged with their children during active addiction.

Recommend therapy to fathers to address issues of abandonment from early childhood, which may have triggered their addiction. Therapy may also address depression and experiences with father hunger and father wounds, which, if unhealed, can negatively impact the father’s relationship with his own children (Real, 1997).
• Provide behavioral couples counseling. This evidence-based practice helps couples identify strategies to cope with challenges faced in early recovery; identify obstacles that impede recovery; avoid high-risk situations; prevent relapse; and communicate more effectively with each other and improve their relationship. This approach has been helpful in increasing recovery rates among parents, which leads to psychosocial improvements in their children and adolescents (Fals-Stewart, 2002; SAMHSA, 2004).
• Recommend a parenting course. Many people find themselves parenting similarly to the way they were parented. If this approach has not been effective, a parenting course may be helpful. It is also recommended that chemical dependence programs routinely provide parenting courses for fathers in recovery. Research suggests that this is a part of providing gender-responsive treatment for chemically dependent men (McMahon, 2008; Lowinson, 2005).
• Organize or refer fathers to weekend retreats. These programs allow men get together on weekend retreats with other men to do work around resolving their own father/son issues and identifying strategies to be better parents in the lives of their own children (Bly, 2004).
• Encourage fathers to stay sober! This offers the greatest chance of repairing relationships with children and offers the possibility of hope from the child’s perspective (Brown et al, 2000).
• Provide fathers with recovery coaches. Recovery management is an emerging approach in the addictions field geared toward the treatment of addiction. It focuses primarily on treating addiction similarly to the way we have treated other chronic and progressive illnesses, such as cancer and diabetes. It is a longer-term approach. It calls for the use of recovery coaches—individuals in recovery who work with clients ongoing in their natural environments, providing support as they tackle the difficult issues of the day, such as repairing relationships with their children in recovery (White, Kurtz, & Sanders, 2006).
• Discuss expectations. Many fathers expect immediate results. It may be helpful to let them know that many years of neglect, anger
and frustration are often not forgiven immediately. This may be difficult for many men in early recovery to handle. It is helpful to increase recovery support as one goes through a gradual process of repair. Repairing family relationships is a developmental process. Brown et al (2000) identifies four developmental phases of family recovery, including the early recovery phase, which he refers to as the “trauma of early recovery.” This phase can last three to five years, with numerous ups and downs and crises, as the family strives to improve relationships and develop a sober identity. Understanding recovery from a developmental perspective should help chemically dependent men in recovery understand what to expect as they strive to improve relationships.

There is a crisis of fatherhood in our society today, as over half of children are being reared without their fathers in the home. The cycle of childhood abandonment and heavy substance use among adolescents can occur in families across multiple generations. The joy of recovery is that chemically dependent fathers are in the position to help repair relationships with their children, thus playing their role in breaking this cycle.

Mark Sanders, LCSW, CADC, is a member of the faculty of the Addictions Studies Program at Governors State University, He is an international speaker in the addictions field whose presentations have reached thousands throughout the United States, Europe, Canada, and the Caribbean Islands. He is co-author of Recovery Management and Relationship Detox: How To Have Healthy Relationships in Recovery. Mark can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

References
Brook, D.W., Brook, J.S., Ruebenstone, Zhangc, Singer, M., Dukes, M.R. (2003). Alcohol Use in Adolescents Whose Fathers Abuse Drugs. Journal of Addictive Disorders, 2003 22(1):11–34.
Brown, S., Lewis, V., & Liotta, A. (2000). The Family Recovery Guide. Oakland, CA.: New Harbinger Publications, Inc.
Bly, Robert (2004). Iron John: A Book About Men. Cambridge, MA: Da Capa Press.
Cooke, C.G., Kelley, .C., Fals-Stewart, W., Golden, J.C. Comparison of Psychosocial Functioning of Children with Drug- vs. Alcohol-Dependent Fathers. Journal of Drug and Alcohol Abuse. November: 30(4): 695–710.
Cristoffersen, M. & Soothill, K. (September 2003). The Long-term Consequences of Parental Alcohol Abuse. Journal of Substance Abuse Treatment, 25(2): 107–116.
Fals-Stewart, W., Kelley, M.L., Cooke, C.G., Golden, J.C. (2003). Predictors of the Psychosocial Adjustment of Children Living in Households of Parents in Which Fathers Abuse Drugs: The Effects of Post-natal Parental Exposure. Journal of Addictive Behaviors. August, 28(6): 1013–31.
Fals-Stewart, William (2002). When Fathers Recover, Children Improve. Clinical Psychology, 70: 417–427.
Haughland, B.S. (2003). Parental Alcohol Abuse: Characteristics in Family Functioning. Child Psychiatry in Human Development, 34(2): 127–146.
Kinney, J. (2002) Loosening the Grip, 7th Edition, Boston, MA: McGraw Hill.
Larson, E. (1985) Stage II Recovery: Life Beyond Addiction. San Francisco, Harper.
Lowinson, J., Ruiz, P., Millman, R., & Langrod, J. (2005) Substance Abuse: A Comprehensive Textbook, 4th Edition, Philadelphia, PA: Lippincott, Williams, and Wilkins.
Mayeda, S. & Sanders, M. (2007). Counseling Difficult-to-reach Chemically Dependent Adolescent Males. Counselor, 8 (2).
McMahon, T. & Rounsaville, B.J. (2002) Substance Misuse and Fathering. Addictions, 97(9): 1109–15.
McMahon, T., Winslow, J., & Rounsaville, B. (2008). Drug Abuse and Responsible Fathering: A Comparative Study of Men Enrolled in Methadone Treatment. Addiction, 103(2): 269–283.
Parke, R.D. (2002) Substance-abusing Fathers: Descriptive Process and Methodological Perspectives. Addictions, September; 97(9): 1118–19.
Real, Terence (1997). I Don’t Want to Talk About It: Overcoming the Secret Legacy of Male Depression. New York, NY: Fireside Press.
SAMHSA (2004). Substance Abuse Treatment in Family Therapy, TIP 39, Rockville, MD.
Sanders, M. & Mayeda, S. (2008). Daddy’s Little Girl: Fatherlessness and Substance Abuse in Adolescent Girls. Counselor, 9 (5).
White, W., Kurtz, E., & Sanders, M. (2006). Recovery Management. Chicago, IL: Great Lakes ATTC.

Methamphetamine use is widely recognized as a problem that has ravaged many parts of the country, with rural areas being particularly hard hit (California Department of Alcohol and Drug Programs, 2007). The drug carries detrimental consequences not only for the users, but also for the communities in which these users reside.

Many communities have seen problems ranging from increased violence and crime, family deterioration and environmental contamination, to strains on child welfare  agencies that are having to place children displaced in law enforcement raids on residences where methamphetamine is manufactured or used.

Recovery management is an emerging approach geared toward treating addiction, similar to how other chronic and progressive illnesses, such as cancer and diabetes, are treated (W. White, E. Kurtz, & M. Sanders, 2006). This treatment is usually longer term and often is anchored in the client’s natural environment. There are three phases of recovery management, which make it an ideal approach with methamphetamine users—pre-treatment recovery support, in-treatment recovery support and post primary treatment recovery support.

Pre-treatment recovery support
This phase often involves the use of recovery coaches (individuals in recovery) who engage clients in their natural environments prior to treatment, with the goal of motivating them to seek help for their addiction. In spite of the fact that methamphetamine use is a continuous crisis in rural America, methamphetamine users constitute only eight percent of all U.S. treatment admissions (SAMHSA E-Network, 2009). Their symptoms (i.e., apathy, feelings of depression, isolation, involvement with destructive peer groups and physical deterioration) make it difficult for methamphetamine addicts to reach out for help (California Department of Alcohol and Drug Programs, 2007). I recently heard a CSAT administrator state, “If they’re not coming in, we’ll have to go out and get them.”

In-treatment recovery support
Approximately 50 percent of chemically dependent clients leave treatment prematurely (White, 2005). Methamphetamine addicts have biopsychosocial challenges (California Department of Alcohol and Drug Programs, 2007) that make completing primary treatment even more difficult, including: memory deficit , which makes it difficult to grasp materials presented in treatment; intense cravings that send them rushing out the door, against medical advice, to purchase methamphetamines; depression, resulting in a lack of energy to participate in treatment; and heightened emotionality and anger, which can lead to outbursts and a tendency to leave treatment early or be administratively discharged.
One study indicated that 50 percent of methamphetamine addicts drop out of inpatient treatment prematurely, and 70 percent drop out of outpatient treatment (California Department of Alcohol and Drug Programs, 2007).

A promising approach is the use of recovery coaches to engage clients during their initial treatment, in order to encourage and motivate them to complete primary treatment. These recovery coaches also can serve as a link to the outside world, as 80 percent of clients who relapse do so within 90 days of completing treatment (White, 2005). The State of Connecticut uses volunteer recovery coaches to meet with clients while they are in primary residential treatment. While they are inpatients, the recovery coaches provide recovery support and then follow up with weekly phone calls for 12 weeks following discharge. Research reveals that 80 percent of these clients are still sober at the 90-day period (White, 2008).

Post-primary treatment recovery support
Methamphetamine addicts face many difficulties upon discharge that make staying sober a challenge (Ojbert J.L., 2000), including:
• Criminal record—Methamphetamine users are more likely to be under criminal justice supervision than other clients, making it difficult to secure employment.
• Intense cravings—This often lures meth users back to active addiction.
• Depression and anhedonia—For approximately one-and-a-half months following discontinuing use, meth addicts often feel depression and have difficulty achieving pleasure from anything other than drug use. This increases the chance of relapse.
• Difficulty with memory and cognitive impairment

Clients requiring the greatest recovery support include those with the highest problem severity and lowest recovery capital (i.e., internal and external assets that aid in recovery efforts) (White, W. & Cloud,W., 2008). According to Brecht (2005) these include clients who: live in rural communities where there are often fewer resources and for which they have to travel long distances to access; have less education than a high-school diploma; suffer with co-occurring disorders; with histories of sexual trauma; started using methamphetamines at an early age; have greater severity of meth use; and inject methamphetamines.

Recovery coaches can arrange for a range of services to these clients in early recovery, including: social recovery support; assistance in arranging travel to and from treatment resources; vocational and occupational recovery support; symptom management support; help with problem solving and decision making; help with disengagement from drug cultures; help with linkages into communities of recovery; and support around family reintegration.

Rarely, in modern history has a drug developed such a stronghold over rural America in such a short period of time. Recovery management offers clients, families and communities a great deal of recovery support before, during and after primary treatment.

Mark Sanders, LCSW, CADC, is on the faculty of the addictions studies program at Governors State University. He is a consultant for Great Lakes ATTC and CEO of On The Mark Consulting, an international training and consulting organization.

References
Brecht, M.L., Greenwell, L. & Anglin, M.D. (2005). Methamphetamine Treatment: Trends and Predictors of Retention and Completion in a Large State Treatment System (1992—2002). Journal of Substance Abuse Treatment, 29(4), pp. 295–306.
California Department of Alcohol and Drug Programs (2007), Methamphetamine Treatment: A Practitioner’s Reference (2007) Sacramento, CA .
Gonzales, R., Marinelli-Casey, P., Shoptaw, S., Ang, A.& Rawson, R.A. (2006). Hepatitis C Virus Among Methamphetamine-dependent Individuals in Outpatient Treatment. Journal of Substance Abuse Treatment, Vol. 31, pp. 195–202.
Hoffman, D.B. & Lefkowitz, R.J. (1993). Catecholamines and Sympathomimetic Drugs. Pharmacological Basis of Therapeutics 8th Edition, New York: McGraw-Hill, pp. 187–220.
Holton, W.C. (2001). Unlawful Lab Leftovers. Environmental Health Perspectives, 109(12) A576.
Olbert, J.L., McCann, M.J., Marinelli-Casey, P. et al (2000). The Matrix Model of Outpatient Stimulant Abuse Treatment: History and Description Journal of Pschoactive Drugs, 32(2), pp. 157–164.
Cognitive Deficits among Methamphetamine Users with Attention Deficit Hyperactivity Symptomatology, Journal of Addiction Disorders, Vol. 21, pp. 75–89.
SAMHSA (2009) TEDS 2007 Highlights Report http://
oas.samhsa.gov/TEDS2k7highlights/TOC.cfm
White, W., (2008) Perspectives on Systems Transformations. Chicago, IL: Great Lakes ATTC.
White, W., Kurtz, E., Sanders. M. (2006) Recovery Management. Chicago, IL: Great Lakes ATTC.
White, W. (2005) Recovery Management: What if We Really Believed that Addiction Was a Chronic Disorder? Chicago, IL: GLATTC Bulletin.

Henry is 44-years-old, married and has two young children. He works as an international business consultant and is home only one to two weeks per month.  A big part of the job is spent socializing with clients over drinks. Between the travel and the alcohol, he is experiencing marital discord, anxiety and constant fatigue. He would like to get treatment but is never in one location long enough to commit to it.

Carole is an overweight married mom in her mid-30s. She lives in a rural community and works from home in sales. She takes over-the-counter medications during the day to maintain her energy and manage her appetite. In the evenings, she relaxes with her husband over what she refers to as “a glass of wine.” Some recent medical problems prompted her to see her doctor who told her that she must stop drinking and find an alternative method for managing her weight. The closest treatment program is 50 miles from her home.

Jake is a student in his early 20s at a local university. He says he only parties with his friends on weekends. He is a scholarship athlete in the middle of a winning season, and  although he participates in practice and games, lately his grades have been slipping and he is facing a possible “incomplete” in one of his classes. He has been fighting with his girlfriend about his drug abuse and is ready to get some help. He is concerned about his privacy and wants to remain in school, but in order to retain his scholarship he needs to pass all of his courses.

Internet-based rehabilitation is a great option for each of the people in the above examples. Although their relationships or work performance have been affected by their abuse, they continue to participate in daily life activities. Enrolling in a traditional residential treatment program would pose a major interruption in the parts of their lives that are working. Consistently showing up for an outpatient program several times per week presents other logistical challenges.  

Online treatment offers three major advantages over traditional counseling: accessibility, anonymity and affordability. Using powerful tools such as video conferencing, online libraries, webinars, self-study materials and online group therapy sessions, quality treatment can now be available anywhere internet access exists.  Furthermore, with the advent of social networking platforms such as Facebook, online treatment is evolving as a natural modality.

In terms of accessibility, online treatment provides several advantages. Online rehab programs can provide a responsiveness that may not be available in traditional treatment. Immediate personal assistance can be accessed in the moment when it is needed. Clients will not have to wait until their session is scheduled in order to receive a response. Help is readily available. For the busy, on-the-go client, regularly scheduled office visits may not be possible. Web-based treatment can be scheduled to accommodate a person’s active lifestyle, thereby allowing the client to retain the functional aspects of their routines while getting help in other areas.

Recognizing that different individuals learn and change in different ways, web-based treatment can offer accessibility in terms of individually created programs. Participants can access a multitude of modalities via the web, utilizing methods that are most effective for their needs and style. Responsive therapists and counselors can be matched to the specific relational needs of each particular client.

Not all potential clients live in major metropolitan areas where there are many qualified therapists with experience and credentials to choose from. Another area in which online treatment provides accessibility is in the ability of the client to interact with highly competent therapists who are available without the constraints of physical location.

Anonymity is an essential cornerstone of a successful treatment process. As people become increasingly confident in expressing themselves via the internet, online therapy is a natural progression. With internet-based treatment, all the standard confidentiality agreements binding counselor and patient remain in place, combined with the additional privacy of participating in a therapeutic process in which your physical appearance and identity remain concealed. Clients won’t be running into one another in the office waiting room or in group sessions, and they are identified only by their screen names.  These facts can help clients to feel more comfortable in openly sharing their personal issues.

In the current economic climate, perhaps the most tantalizing incentive for online treatment is its affordability. By bringing treatment to the web, online programs save on the expenses of maintaining a physical office space. Keeping operating costs low helps online services spend more time and resources on improving treatment content for their clients. From the client’s perspective, online treatment is much more affordable than traditional rehab options, which can cost upwards of four to five months in mortgage payments.  Since all interactions take place online, clients also save on travel expenses.  Addition­ally, clients are able to continue working and generating income while getting help.

Online therapy is a relatively new development, but early reports already attest to its effectiveness. A recent study conducted by Johns-Hopkins University found that “Internet-based counseling can reduce [concerns of patient resistance and non-adherence] by allowing patients to participate from home” (King, van L., et al., 2009). Numerous studies also attest to the success of forerunners to today’s fully-fledged online treatment, such as e-mail counseling and online questionnaires.

Web based treatment is poised to become an increasingly popular avenue. The rewards of accessibility, anonymity and affordability give it the potential to reach countless people around the globe who need help. The success of online treatment lies in its creative application of user-friendly modalities and the service of highly qualified professionals who can transmit via the internet their care and commitment to clients seeking recovery.

Dr. Nancy Sobel is a licensed psychologist in private practice in Los Angeles, California.  She is the Executive Director for the online rehab program called 12 Visions International. She can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it


References
King, van L., et al. (2009). “Assessing the effectiveness of an Internet-based videoconferencing ­platform for delivering intensified substance abuse counseling.” Journal of Substance Abuse Treatment, 36(3), 331–338.