Extreme makeovers ... addiction professionals know all about extreme makeovers. No, not the reality TV shows where people undergo radical cosmetic surgeries to improve their physical appearance, but the makeovers that happen when a person leaves addiction for a life of recovery, sobriety, and hope.

Addiction professionals see extreme makeovers every day as patients start over. Some arrive at sobriety through treatment, others through self-help groups, and others with a combination of both. In treatment, patients learn about the disease and with professional help look at the nature and extent of harmful consequences associated with their addiction. They slowly acquire the tools necessary to begin and maintain sobriety. Residential treatment affords patients a brief respite from a chaotic, unsafe, or disruptive home environment. With outpatient treatment, patients learn recovery skills while having a chance to practice them in their own environment.

Truths about treatment
Consider the following research-based principles of addiction treatment (National Institute on Drug Abuse, 1999a):
• Addiction treatment needs to be
readily available.
• Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use.
• Remaining in treatment for an adequate period of time is critical for treatment effectiveness. Research indicates that for most patients the threshold of significant improvement is reached at three months, and that additional treatment can produce further progress toward recovery.

In reality, addiction treatment in this country is not readily available for all who need it. In fact, by some estimates nearly two-thirds of those who need it do not receive it (SAMHSA, 2000). Treatment is often not fully covered by health insurance. There are often caps or restrictions on both the length and type of addiction treatment benefits. For low income and public pay clients, especially in non-urban areas, options may be even more limited.

Short periods of abstinence, like detox or time spent in jail, in the absence of treatment, do little to change behavior and support recovery in the long haul. While addiction professionals know that jail is not the same as treatment, the general public is often surprised, for example, when an addict who has not received treatment continues to use while out on pre-trial release. This is often cited as evidence that “treatment doesn’t work.”

Funding sources, not patient need, too often drive the length of treatment exposure. For example with methamphetamine addicts, adequate treatment time is needed to sort through the psychiatric conditions to determine which may be pre-existing and which are the esult of the methamphetamine addiction. Methamphetamine addicts also need time and support in the early months of recovery.

Research demonstrates that ongoing counseling and participation in a Twelve Step program (such as Alcoholics Anonymous, or Narcotics Anonymous) boost treatment effectiveness even more (NIDA, 1999b). Simply put, patients who receive more counseling sessions and those who have greater participation in Twelve Step programs do better.

One study (Fiorentine, 1997) found that patients who had more counseling sessions had better outcomes than patients who had fewer sessions. Another study (Fiorentine, 1999) found that those who attended just one Twelve Step meeting per week after completing addiction treatment had significantly less drug use than those who participated less. A third study (Fiorentine & Hillhouse, 2000) found that patients who participated in Twelve Step meetings before and during treatment were significantly more likely to stay in treatment longer, complete treatment, and participate in Twelve Step programs after treatment. Thus there appears to be a positive additive effect that results in better outcomes when Twelve Step participation is coupled with treatment.

Why halfway houses?
In this day and age when treatment services are squeezed in terms of availability and duration, halfway houses can facilitate both additional counseling and Twelve Step participation, thus improving outcomes and a person’s chance for a sustained recovery. Halfway houses offer patients an opportunity to practice what they learned in treatment, while holding down a job and living in a safe, sober, supportive living environment. People also get an introduction into the recovery community through participation in Twelve Step programs. They get the chance to transition back into the world and practice their recovery skills while doing it.

Treatment is the beginning stage of recovery when patients receive education about the disease, the tools of recovery, and relapse prevention. Some say the real work of recovery begins when you walk out the door of a treatment center back into the “ real world.” While addiction is a chronic disease that can be managed through behavioral change (similar to diabetes, hypertension, or asthma), some people do not always see it that way.

Many places still view addiction as a moral failing or willful misconduct. Given this attitude, it’s no wonder that many communities continue to ostracize and marginalize recovering addicts and alcoholics, instead of lending a hand to help them stay on their feet.

In city council meetings across the country, local residents clamor, “Not in my backyard!” in response to the prospect of halfway house in their neighborhood. But or fifty years St. Paul, Minnesota has been home to what is now one of the longest-standing continuously operational halfway houses in the country, Hazelden’s Fellowship Club. It has been a home base to about 10,000 residents who have needed time to work on recovery skills while integrating back into work, community, and family life.

What makes Fellowship Club work?
One of the reasons that Fellowship Club has been a stable part of the community and not fallen to the pressures of NIMBY is because of its history. Certainly in its early days it faced concern from neighbors, yet over time it became an institution that provided service to the community instead of taking resources from it.

For many years, Fellowship Club residents have done “spot jobs” in the neighborhood, jobs where the neighbors call and ask for someone to help them move, rake leaves, landscape, clean, for example. Neighbors are screened to provide a safe environment in which residents can work, and are asked to pay the going rate, currently $10 an hour. This provides a service to the community and some upfront cash for residents when they first come to Fellowship Club. In addition, Fellowship Club has made a concerted effort to fit in well with the neighbors by maintaining the building and grounds. Many neighbors have commented on the fact that they like Fellowship Club in the neighborhood because “Hazelden keeps up its property.”

Speaking from our experience, people from many areas of the country and the world, of all socioeconomic status, religions, and diverse cultures started their journey of recovery at Fellowship Club. They have done this with the supportive fellowship of others, many of whom they would not otherwise meet, much less live with or befriend. What holds them together is their common path, their recovery.

What was true 50 years ago is still rue today: people need time, support, and structure when they are new to recovery. They need time to practice their new sobriety skills and behaviors. They need structure and predictability. It’s as if treatment gives people the theory and halfway houses give them the practice.

Halfway house days
Days at Fellowship Club are structured to provide residents “practice” in recovery, a chance to be out in the “real” world, with the support of others to put a recovery lifestyle first.

The first week at Fellowship Club, residents are asked to take part in orientation week. The week includes groups around application and interviewing techniques, résumé writing, using public transportation (which includes a bus tour of St. Paul), financial management, personality testing, relapse prevention, and other groups that assist into the transition to community living.

A typical day starts with residents asked to do chores that are part of daily living. All are required to make their bed and participate in some chore to keep the community areas of the house clean or to keep the house functioning. These chores, called “therapeutic duty assignments,” can be picking up or cleaning a community area or having phone duty that evening for the resident phone lines.

Residents are required to work 32-40 hours a week and to get Monday through Friday employment. Residents are encouraged to get “recovery jobs” and not career jobs. These jobs are ones that one can show up and work but don’t require much thought or work when one leaves the job site. Residents need to put their energies on putting their recovery first. For some, just getting in the structure of working a regular schedule is more than enough stress. If residents are not responsible for their own bill at Fellowship Club, they are asked to contribute $50 per week of their earned money toward their stay. This is a way to start to take responsibility for their treatment and recovery.

All residents are expected to be back at the house at 6:00 PM for dinner. Dinner is served family style. Fellowship Club has found that there is something about eating a meal together, putting one’s feet under the same table at the same time, that provides for informal sharing that is so
important in recovery. Twelve Step groups have described this type of sharing as the “meeting before the meeting”

Evenings are spent in treatment activities: groups, lectures, community meetings, individual counseling appointments or going to outside Twelve Step meetings. Residents are required to attend three outside Twelve Step meetings a week plus one in-house meeting a week. One night a week is free (Wednesday) with no scheduled activities in the house except for dinner.

Treatment is based on the Hazelden model of education, therapy, and fellow ship. Fellowship happens as residents share the daily happenings of recovery life, both the ups and downs. Education is provided one to one, in groups and in lectures. Therapy happens individually and in groups. An onsite mental health clinic assists residents who have co-occurring mental health issues. Medical needs are referred to community resources.

While many residents describe Fellowship Club as “freedom” following their very structured time in residential treatment, for some, “freedom” can also translate into “boredom.” Many people early in recovery have no idea what to do with their time that in the past they spent using, thinking about using, or recovering from using. Part of being at Fellowship Club is trying some new activities that one may not have tried previously, or that one may not have done sober. It could be as simple as a volleyball game on the grounds that encourages fresh air, some movement and some team work or as complex as setting up sky diving lessons. Either way, socialization and leisure skills are stretched as one starts to do different things in recovery. Saturday mornings at Fellowship Club are filled with required groups, however Saturday afternoon and evening and all day Sunday are free time. Residents are encouraged to fulfill their Twelve Step meeting requirements during this time, but also to do some planning for leisure time activities.

Lessons we have learned
In summary, important things Fellowship Club has learned over the 50 years of assisting residents in their journey of recovery include:
• Daily support is crucial for people new in recovery as they “practice” recovery tools.
• Structure in early recovery is imperative (job, chores, Twelve Step meetings).
• It is important for people to take responsibility for their recovery (Twelve Step meetings, sponsor, daily recovery activities, financial investment in treatment).
• Sharing meals is an important part of fellowship.
• The community is an important part of Fellowship Club. A strong supportive Twelve Step community allows residents the support for ongoing recovery. Fellowship Club is a feeder system to that community. Residents also learn the importance of serving their community through community service.
• Self-esteem comes from showing up and doing what’s needed, not from talking about it.

It is not always a smooth journey. For someone fresh in recovery, for example, a brief reprimand or harsh tone from a boss can be a major issue to work through alone. A disparaging remark about a “drunk” or a “doper” can be difficult to overhear. Learned reactions to stressful situations are hard to abandon, and new behaviors don’t often come easily. Going to the first Twelve Step meeting can be overwhelming alone, but much more comfortable with and inviting in the company of a peer.

The gift of time, support, and structure helps people look the world in the eye again, as they become citizens of a world that once rejected them and that they once rejected. As residents arise and go to work every day, you see both struggle and hope in their eyes. Eventually, you see more hope than fear, more pride that defeat. And then gradually, you see them standing confidently and competently on their own two feet.

Brenda Iliff is the executive director of transitional care at Hazelden’s Fellowship Club.

Carol Falkowski is the director of research communications at the Hazelden Foundation, and author of Dangerous Drugs: An Easy-to-Use Reference for Parents and Professionals.

References
Fiorentine, R., & Anglin, M.D. (1997). Does increFiorentine, R., & Anglin, M.D. (1997). Does increasing the opportunity for counseling increase the effectiveness of outpatient treatment? American Journal of Drug and Alcohol Abuse 25(3): 369 -382.
Fiorentine, R. (1999). After drug treatment: Are 12-step programs affective in maintaining abstinence? American Journal of Drug And Alcohol Abuse, 25(1): 93-116.
Fiorentine, R., & Hillhouse, M. (2000) Drug treatment and twelve-step program participation: The additive effects of integrated recovery activities. Journal of Substance Abuse Treatment, 18(l): 65-74.
National Institute on Drug Abuse. (1999a). Principles of Addiction Treatment: A Research-Based Guide. US Department of Health and Human Services, National Institutes of Health National Institute on Drug Abuse, NIH Publication No. 99-4180.
National Institute on Drug Abuse. (1999b). “Adding More Counseling Sessions and 12-Step Programs Can Boost Drug Abuse Treatment Effectiveness,” NIDA Notes, Vol. 14, No. 5, US Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse, NIH Publication No. 99-3478.
Substance Abuse and Mental Health Services Administration. (2000). Summary of Findings from the 1999 National Household Survey on Drug Abuse, U.S. Department of Health and Human Services, DHHS Publications No (SMA) 00-3466.

This article is published in Counselor,The Magazine for Addiction Professionals, December 2004, v.5, n.6, pp.57-62

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