For many years I conducted early recovery groups as a guest presenter in multiple inpatient, residential, and/or ambulatory treatment programs for clients with co-occurring substance use and psychiatric disorders (CODs). I also conducted recovery and/or focus groups at a therapeutic community program in the inner city, and for incarcerated adolescents or adults with CODs. I met regularly with clients to find out what their concerns were related to recovery from CODs, what they found helpful in COD programs, and what else they thought could help their recovery. I continue to be a guest presenter in several intensive outpatient programs (IOPs). This article provides a summary of what I learned from these experiences and the challenges shared by clients with CODs.
Focus Groups of COD Clients
Adult and adolescent clients in inpatient or residential settings often expressed the desire for more weekend groups because they thought they had too much free time on weekends. While they valued group treatments, clients felt strongly that individual sessions were needed. Many felt they did not get enough time in individual sessions with clinical staff. There was variance between programs and staff within a program in terms of how much individual time was given to clients. The importance of a therapeutic alliance with staff members who spent sufficient time with clients in individual sessions to explore their personal recovery issues was clearly articulated. Individual sessions enabled clients to open up, trust, and disclose personal feelings and struggles with their CODs.
Clients could tell which staff members they believed were the most approachable, empathic, and willing to give them personal time and attention. My recommendation for all hospital, residential, and/or ambulatory rehabilitation programs that are primarily group-based is to provide regular individual sessions to clients as a way to explore issues and concerns not discussed in groups.
Many clients reported how bad they felt when they perceived negative judgement from staff who did not understand what it was like to have both a substance use disorder (SUD) and a psychiatric illness. This was more likely to occur in a mental health treatment system with staff who did not have sufficient knowledge, skills, or comfort level in addressing substance use issues. Mental health practitioners need to expand their clinical capabilities and comfort level to address substance use issues, and addiction practitioners need to expand their capabilities to address mental health issues.
Inside Recovery Group Discussions
My recovery groups usually include up to twenty clients and are conducted in an interactive way to actively engage participants. The goals are to educate, raise awareness, give hope, and stimulate interest in active recovery. Most clients have been in multiple psychiatric and/or addiction programs, and a good number have been incarcerated. While all levels of severity of CODs are represented, most have moderate or severe types of disorders. Many also have medical and other psychosocial problems that require help from other providers.
I ask members to introduce themselves, state what problems brought them to treatment, and identify one recovery issue they would like to discuss. Group leaders also attend this discussion and one writes the list of issues on the dry-erase board. I walk around the room during the session and ask questions or seek clarification of issues raised; elicit self-disclosure of clients’ struggles in recovery or what helps them cope with the challenges of recovery; share stories of successes of others with CODs; share information based on research; and share insights on what I have learned from others suffering from CODs. I sometimes ask clients to comment to each other about recovery issues or coping strategies that have helped them so they share support and learn from one other. The group ends with clients stating one thing they learned from the discussion that may help them in their ongoing recovery.
Recovery Issues and Challenges Shared by Clients
Most groups identify the following topics for discussion: motivation struggles, causes of the disorders, negative emotions or moods, high-risk people and places, family conflicts, social- and mutual-support programs, medication-assisted treatment (MAT), strong cravings, and/or how to stabilize from a relapse. While not all of these issues are discussed in a single session, following is a summary of key issues often discussed. After my group ends, clients return to their IOP therapy groups and process the issues we discussed.
Motivation and Adhering to the Treatment Plan
Group members express various levels of motivation, from low to moderate to high (about one-third in each category). We discuss how showing up for group, other counseling, medication appointments, or mutual-support meetings is one of the best antidotes for periods of low motivation. Clients report they feel much better when they push themselves and adhere to sessions. Some state this helps divert a relapse because they often want to use when they wake. I share insights from research and our experiences with thousands of clients in our programs in that those who adhere to treatment do better in the short and long run. “Drag your body and your mind will follow” is one of the main messages given.
Many clients are perplexed as to why they continue to drink or use drugs since their SUDs have created problems with their health and in their lives. We discuss why they continue to use substances to feel good, escape feelings of depression or emptiness, or prevent withdrawal from physical addiction. We discuss how the brain may adapt to substances, and how they feel they have to use to feel normal. Clients describe memories and stimuli that contribute to cravings that are sometimes overwhelming. We discuss how MAT can help attenuate strong cravings and decrease the desire to use alcohol, opioids, or tobacco. I suggest to clients with alcohol use disorders (AUDs) that they talk with their team about FDA-approved medications available to reduce alcohol cravings or desires. We sometimes discuss the quandary for clients who do not lose control every time alcohol or drugs are used, which raises the question, “Is my SUD that bad?” A message conveyed is that even with an addiction (i.e., a more severe form of SUD), there may be periods of limited or controlled substance use.
Understanding Mental Illness and Treatment
We discuss categories and severity of mental disorders, how these interact with SUDs, and how each disorder affects recovery or relapse of the other disorder. Multiple causes of mental illness are reviewed since some clients have a simplistic view that taking medications to normalize their brain chemistry is all that is needed to get well. A key theme is that improvement for a mental disorder can occur without total remission—that some clients will continue to experience chronic or persistent symptoms of illness. We discuss the difference between single or recurrent episodes of a disorder. Many clients with recurrent disorders who experience remission stop taking medications when they feel good. I share research that shows stopping medications during periods of remission for recurrent major depression increases the risk of a recurrence of a new episode of depression. A key message is that clients should not make decisions about stopping medication or therapy on their own without discussing this desire with a provider, sponsor, and/or confidante.
Effects of CODs on Self and Families
Clients identify numerous adverse effects of their disorders on their health, functioning, and loved ones. Guilt, shame, fractured family relationships, and many other negative effects are shared. Many report high rates of disorders in their families, which leads to discussing how some individuals are at increased risk to develop a disorder based on family history. I emphasize that continued involvement in treatment and recovery, and involving the family when feasible, are the best ways to gradually reduce these adverse effects. Clients need help determining how and when to address issues with their family, or how to get them involved in treatment or recovery.
We discuss the importance of “active involvement” in recovery as a way of managing CODs. We review domains of recovery, roadblocks, and what helped clients in the past since many have had episodes of stable recovery from either or both types of disorders. When I ask clients to state Step One of the Twelve Step program, they usually start with the word “I.” I change the focus to “We” to facilitate connecting with peers in recovery rather than taking a solo approach. I emphasize the importance of reducing negative and increasing positive attitudes (e.g., openness to learn), challenging faulty thinking, learning and using basic recovery skills (e.g., managing negative emotions), and gaining knowledge about their disorders, treatment options, and paths to recovery. I share findings from clinical trials and recovery surveys from the US and other countries to show that long-term involvement in recovery is associated with improvements in all areas of life: health and engagement in healthy behaviors, mental health, spiritual health, family relationships, work and employment, financial condition, and community involvement.
We discuss the need to take sufficient time to stabilize from a current relapse or recurrence of illness. Then, as time progress, clients can identify early signs of relapse and high-risk factors to address some of these issues during their treatment episode. I find it helpful to share the insights and research summaries of William White from his blogs, articles, and books. His focus on recovery is exceptional, and he offers many tools to aid clients in enhancing their recovery and reducing relapse risk.
Social Support and Mutual-Support Programs
We discuss the need for positive social support as a way to avoid or reduce the impact of negative people and/or unhealthy relationships on recovery. We discuss common resistances to reaching out for help and support, and reasons why so many clients do not participate in community mutual-support programs. I share research on the benefits of active involvement in mutual-support programs. We discuss different types of mutual-support programs with the caveat that many communities have few or no non-Twelve-Step programs. We also discuss tools such as chat rooms or smartphone applications to aid recovery. Messages conveyed are to find a path to recovery, change it if it does not work, and let others be supportive.
Sharing time in group with IOP members is always one of the highlights of my day. I am grateful to have the chance to remain in the trenches helping others fighting for their recovery. What impresses me is that many clients, despite their complex histories of multiple disorders and related psychosocial and medical problems, want to improve their lives. They listen attentively, engage in meaningful discussions, self-disclose their struggles, and show openness to new ideas.
I am also impressed by the resilience of clients who make decisions to reengage in treatment after periods of relapse or recurrence because the healthy part of them wants recovery and is willing to take steps to regain it. Since I have been part of this program for decades, I often see clients who have returned for another episode of treatment—some express guilt and shame when they see me, and judge themselves harshly. I tell them I am glad to see them, and that returning to treatment shows they want to get back on track in recovery and improve their lives. Many of these clients need to increase their self-compassion.