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Families often become overwhelmed while trying to decide on the right rehab center for their loved one. What we have come to realize after decades of experience is families are not always looking for treatment centers that are right for their loved one. They are often looking for rehabs that are right for themselves. What we mean by this is codependency and maladaptive behaviors are often carried into the rehab center selection process by both family and substance users. Neither the substance user nor their family is always looking for a rehab center or treatment plan with the most effective results; even though they think they are. They are often subconsciously looking for the right rehab center that is the most comfortable. In addition, the substance user is almost always looking for a quick fix or a shortcut to recharge their batteries close to home to get their family and others such as spouses, employers, courts and creditors off their back. Many substance users attend a rehab center to get their stuff back or to throw the scent off the dogs. They often check in addressing the symptoms and not the behaviors and past experiences such as trauma and negative physical and emotional experiences. Not all substance users do this, and many do. This is partly the reason for today’s treatment outcomes that are approximately 3% effective. Far too often families and substance users choose what they believe to be the right rehab center may be choosing the center for the wrong reasons.
Another contributing factor to these dismal results is families not engaging in their own recovery while learning about enabling, codependency, boundaries, and accountability for the substance user and themselves. The right rehab center should include clinicians who consider the families plight during the addiction and consider the family in the recovery process and discharge plan, another component of effective treatment that is very often missed or not considered during the selection process.
For many families and substance users if I were to tell them there was a rehab center out of state, over two thousand miles away, the substance user could not have their phone, they were going to focus on the behavior and not the symptoms such as losses of things as the priority, it was in the middle of nowhere and was a 180 day commitment that came with a guarantee of lifelong sobriety you would think both substance user and family would stop their search and get there immediately. Now while sadly, this doesn’t exist, even if it did, it would not be the case that those searching would stop their search and attend the rehab center with the guaranteed solution that focused on the behaviors and trauma. They would still most likely be focused on the comfort and not on addressing the symptoms, problems, and causes.
Many times the substance user and the family search for the solution in the same manner in which they stayed in the problem; avoiding discomfort and uncomfortable change, and believing the substance user just has to fix the problems that were caused by the addiction. Families and substance users are also searching for a solution in a flooded state with a distorted perception caused by the trauma and negative experiences of the addiction. Family codependency and enabling causes many families to look for quick fixes backed by the substance users promise that they will get it right this time. Very rarely do families and substance users realize the problems or symptoms that need to be addressed are caused by behaviors that lead to substance use and not the substances alone. Substance use causes the symptoms or loss of things; the behaviors and self medication cause the substance use come first. Choosing what you believe to be the right rehab center to get back the things you lost while not looking at the reasons you turned to drugs or alcohol is largely in part why many people fail after leaving the rehab center. As a result of distorted treatment selection, the first thing the family and substance user does next when the substance user resumes consuming drugs or alcohol is blame the rehab center for not working.
How to find the right Rehab Center
As stated above, the considerations for choosing the right rehab center are often distorted. Unbeknownst to those searching, they go about it in a maladaptive way. What most people do not know is that nobody has reinvented the wheel nor does any treatment center have a cure or guarantee. Almost every center that is licensed and JCAHO accredited (Joint Commission on Accreditation of Healthcare Organizations) or CARF accredited (Commission on Accreditation of Rehabilitation Facilities) is providing similar services. What they all have in common is they are delivering evidence based treatment. Evidence- based treatments are treatments that have been proven effective in both efficacy and costs by NIAA (National Institute on Alcohol Abuse & Alcoholism), NIDA (National Institute on Drug Abuse), and SAMHSA (Substance Abuse & Mental Health Services Administration). The efficacy and cost effectiveness are based on randomized clinical trials, and reviews. Rehab centers have to offer these types of treatment if they choose to be reimbursed by insurance providers. The majority of people who look for rehab centers search for ones that accept their insurance. For those who choose to or have to self pay for treatment they will be attending treatment centers focused on delivering evidence based care as the majority of curricula rely on insurance reimbursements and therefore are built around evidence based treatments. Whether the evidenced based care will be effective for your loved one or not, and whether you self pay or use insurance, chances are excellent the center you choose will be delivering very similar if not the same services as the one you do not choose. Because treatment centers operate relatively the same, the greatest thing that separates most rehab centers is their marketing strategies by offering more amenities and nicer aesthetics; things that do not necessarily result in a greater chance of sobriety. Rehab considerations that families and substance users should be focused on is what contributes to a greater chance of success. Some of these are effective clinicians who can connect with clients and understand the importance of family system dysfunction and family involvement in the treatment and discharge plan.
One of the number one predictors of successful outcomes is the clients relationship with their clinician. You will rarely if ever see this on a rehab centers website nor will you hear the admission person discuss this with you. This is because it is not what most families and substance users are looking for, they are often looking for comfort, amenities and aesthetics. Regardless of where your loved one attends rehab, if they do not like their clinician, and the family is not in recovery themselves the substance users outcome can and will be compromised. Many rehab centers lack effective family programming and collaboration with the families wants and needs. Most say they offer this and most do not offer it effectively or at all. The most successful rehab centers are those that work with the family on setting healthy boundaries and addressing codependency while holding the substance user and family accountable as they both have an equal part that contributed to the addiction. Considering the family in the discharge planning process and asking the family if they are ok with the discharge plan especially when it involves the substance user returning home or close to home is something that rarely happens with clinicians in rehab centers. In addition to client/clinician relationships and family considerations, here are some other factors that can contribute to a rehab center being a better choice for the substance user and their family.
The question a family has to ask themselves is, what do they truly want for an outcome from their loved one attending a rehab center. Do they want them sober for life or do they just want them back? It is an interesting question and one we see often. Many times the family is subconsciously more interested in getting their loved one back than they are sober; there is a difference. Another problem we face with families trying to find the right rehab center is worrying about what will happen to them while the substance user is gone and what will happen to both substance user and family when they return. Families often choose treatment centers with their own selfish agenda in mind and they aren’t even aware of it. They look for things in a center that do not contribute to higher chances of success, they look for things that will make all those affected happy.
The substance user should set a goal and ask themselves what their goals of attending a rehab center are. Are they just going to rest up and get the family off and others off their back or do they really want to be sober? This is easy to detect as the answer will be clear in where they go, for how long, and how well they follow directions while not dictating the care and the discharge. It is like being asked to take a drug test. The answer is not in the results, it is in the response when asked to take it.
It is ok to have amenities and aesthetics as a goal of treatment selection. Being in a nicer comfortable facility certainly is not going to lessen your chances of turning your life around and becoming clean and sober. The important thing to remember is what really matters. When setting goals, a family and substance user should ask themselves some questions. Good questions to consider would be, are we done trying to run the show and are we ready to turn this over to the professionals who know more than we do? Do we want our loved one back or do we want them sober? Do we prefer a center that helps the family or not? Are we done living this way and if so, are we willing to do whatever it takes to not go back to the old way of living? Does the family realize the importance of their own recovery and what roles they played in the addiction? Lastly, when selecting the right rehab center, ask yourselves, are you more concerned about the outcome or the comfort? Choosing treatment based on comfort will help you in the moment and chances are excellent that comfort will be short lived.
The majority of rehab centers are equipped and are designed in preparation for clients experiencing a dual diagnosis. This means they have staff that can treat both substance use disorder and mental disorder within their integrated treatment team. There are times when after detoxification and stabilization from substances, a present or perceived disorder or ailment may decrease in severity or may even disappear. Other times the condition or ailment may worsen after drugs and alcohol are removed. In most cases, a dual diagnosis facility can accommodate these changes, and other times they may have to refer out to a rehab center that specializes in the now clearer and exposed symptoms of the condition or disorders. Whenever a substance use disorder is present it can cause increased symptoms that appear as a mental disorder or process addiction such as eating or gambling disorder. Until the substance use disorder is stabilized it is difficult to determine how much of the other condition was caused by the substance use or how much of the condition was self medicated by the patient to treat the condition or disorder. Per instructions when attending graduate and doctorate school, the clinician has to consider the substance use disorder as the cause until proven otherwise as substance use can worsen symptoms of other disorders and conditions.
When a substance use disorder is not present in cases such as eating disorder, self mutilation, depression and other mental disorders a speciality program for the specific disorder or condition should be explored. All disorders, including substance use, should have an assessment performed by a qualified professional and not the family or the person needing treatment.
Qualifications are sometimes difficult to discuss. The reason behind this is, just because you have qualifications and degrees does not mean you’re an effective clinician. As stated earlier, one of the number one predictors of outcome is the client/clinician relationship. Does having a PhD or Masters degree make you more or less likable to a client with a substance use disorder?. Some of the best employees of a treatment center that connect with substance use disorder clients are individuals who have a substance use disorder themselves and are now in recovery and who have no credentials at all. What makes up a strong staff at a rehab center is qualified credentialed clinicians with support staff that understands the mind of a substance use disorder client first hand. Qualifications of a clinician should include family systems knowledge and knowing the importance of boundaries and accountability for both family and substance users. The qualifications of a clinician should include having the ability to challenge the client and help them see the impact of their addiction on others. Many times clinicians make friends with their clients and zero in on only looking at the needs and wants of the substance user. Addiction is not a victimless crime and discharging a client to an environment that can negatively impact those in the environment are often overlooked.
Far too often families look for the letters after the name and forgo looking at the ability of the rehab center and its staff to connect with their loved one.
We believe a clinician that has credentials, experience both inside and outside the classroom in the real world can offer the best opportunity of a client/clinician relationship. This is why treatment centers with an integrated treatment team and staff with family systems considerations are in a position to offer the best opportunity for a positive outcome.
Amenities are important for some. As we stated earlier, nice facilities with all the bells and whistles are certainly not going to lessen the chances of one finding a new life and remaining clean and sober. When it comes to amenities, it should be the least on the list of concerns. Nowhere do any of the federal agencies that oversee treatment centers and nowhere in evidence-based treatments does it list amenities as being a predictor of positive outcomes. As long as a family and a substance user sets priorities for their treatment selection towards efforts that increase positive outcomes over amenities than having amenities lowest on your goals is certainly ok.
Some amenities that are beneficial are exercise, outdoor activities, and healthy diet and food choice. These amenities are good for the mind and body and are a great add on to a strong therapeutic curriculum. Amenities should never be put before evidence based treatments. The ones listed here are almost always offered at the majority of centers.
Treatments and therapies
As we stated previously, the majority of treatment centers are offering similar curriculums and evidence-based treatment. Two of the most significant are 12 Step facilitation and Cognitive Behavioral Therapy (CBT); both evidence-based. Group counseling as well as individual counseling are important too. A good group facilitator who understands the group members is able to facilitate effectively by bringing specific group members together to help solve problems through past experiences. A group facilitator who is respected and trusted by the group members can have a significant impact on the outcome of the groups. Another evidenced based approach is BCT (Behavioral Couples Therapy). This involves the significant other or close family of the substance user to be part of the recovery process. Although BCT refers to the significant other, we see the same results when the family is brought together in the same way.
What one does in treatment is important and the treatments and therapies often have an impact that can last a lifetime. Families and substance users should note that staying clean and sober in treatment is far easier than staying clean and sober outside of treatment. Continuing recovery efforts and therapies after treatment is just as important as engaging while in treatment. If the substance user was to only go to treatment and do nothing else when they are discharged, the chances of them maintaining long term sobriety would be very low.
MAT or Medically Assisted Treatment is an evidence-based treatment. One of the most effective methods is Vivitrol for opioid and alcohol users. Vivitrol is an injection that lasts 30 days and is an opioid blocker similar to the drug used to reverse the effects of an opioid overdose called Naloxone. When taken by an opioid user it blocks the effects of opioids while having the potential of reducing the craving for opioids. For alcohol users it has shown great results in reducing cravings, although it does not reverse or stop the effects of alcohol. Among all the medically assisted treatments for opioid users we see Vivitrol as having the greatest impact on positive outcomes. The only drawback appears to be that it is the highest on the list of refused therapies for opioid addicts. Offering Vivitrol is a great barometer to gauge the willingness of an opioid user’s commitment to sobriety. Acceptance of Vivitrol would show a high willingness whereas complete resistance would show little willingness. Once the shot is taken, they know they are not going to feel the effects of opioids for a while. Those with a subconscious thought of relapse or using just one more time would most likely come from those who resist this form of MAT. This is not an absolute and it certainly is a great barometer of one’s willingness.
Treatment plans, therapies and treatments are always changing based on ongoing assessments. As one excels, stays stagnant or backpedals in treatment, your loved ones’ clinical team can help determine which treatments and therapies will be most effective for them and your family throughout the recovery process.
Inpatient vs. outpatient
Determining level of care is based on necessity and ASAM (American Society of Addiction Medicine) and DSM (Diagnostic and Statistical Manual of Mental Disorders) criteria. Most clients who are diagnosed with a substance use disorder as moderate or severe needing detoxification and stabilization will enter an inpatient treatment center after detox followed by partial hospitalization and then outpatient treatment. Almost every intervention client meets ASAM criteria dimension 1 which means they meet criteria for acute intoxication and withdrawal potential. Unfortunately, many families wait until it is an extremely difficult situation for both them and their loved one before they call professionals to help with the family struggles and the addiction.
Inpatient means what it says, you are inpatient and can not leave unless supervised by rehab center personnel. Inpatient’s primary goal is to stabilize the substance user after detox and to prepare them for the next phase of care. PHP or partial hospitalization often follows inpatient treatment. PHP is similar to inpatient other than you move to different housing although your programming during the day is similar. In PHP you are often allowed to engage in more activity and attend outside meetings. When you are discharged to outpatient you receive less programming and at times may still remain in the facilities housing, although this is not always the case. Intensive outpatient (IOP) typically includes 9 hours a week broken up into 3 days with 3 hours a session. Outpatient (OP) is less than IOP and your sessions are reduced based on your treatment team’s recommendations.
Choosing Inpatient versus Outpatient should be made with a professional using ASAM and DSM criteria. Far too often we see the family and the substance user trying to dictate level of care. This goes back to the information above on how and why families and substance users make decisions. They often put comfort before effectiveness and necessity. Surrendering to professionals and following the guidelines of ASAM and the DSM can allow for a more positive outcome in addiction treatment.
Length of program
The National Institute on Drug Abuse (NIDA), one of the organizations that oversees evidence-based treatment, states that for residential and outpatient treatment anything less than 90 days has limited effectiveness. They go on to state that the longer treatment lasts the better the outcome. In our experience when the substance user enters a program that is away from their environment for a minimum of 90 days, followed by outpatient services in a sober living home for an additional 90 – 180 days, with 12 step facilitation and individual therapy, is when they achieve the greatest results.
When a substance user has a decreased ability to leave treatment early against medical advice due to their distance from home and strong family boundaries, it increases the likelihood they stay in treatment and benefit from the complete curriculum of the rehab center. Regardless of whether or not they go far away or for 90 days or less, family boundaries and accountability for the substance user in the event they do not complete treatment and remain clean and sober is often enough to keep them engaged with their ongoing recovery efforts. Very often the substance user will commit to a 30 day program. More often, family boundaries and accountability help the substance user make the decision to stay and continue on for at least 60 more days of treatment and follow discharge instructions.
We understand not all insurance will cover 90 days of treatment and we understand not all families and substance users can afford 90 days of treatment. By discussing various levels of care and treatment options with a professional, they can collectively build a treatment plan that will assist the substance user with staying engaged in recovery efforts for at least 90 days and well beyond.
Like any medical or dental expense, addiction treatment without health insurance or for those who choose to self pay can be expensive. The longer one stays in treatment the less their insurance will pay and the more it will cost. In spite of federal agencies stating the effectiveness of long term treatment, insurance companies often fail in providing the necessary funds to ensure a lengthy treatment stay. The range of rehab center costs is far too wide to state and stating the costs may encourage some to forgo even thinking about offering their loved one help. Costs and long waiting lists for state funded facilities are often deterrents for some to enter treatment willingly. The good news is, some treatment is far better than no treatment at all and there are many avenues and treatment plans available to ensure one receives care.
The more treatment you can get, the better the outcome, that is a proven fact. Working with a professional can help you navigate the substance users needs and determine costs and coverage for those needs. Costs should not be a deterrent for attempting to try and help a substance user. Families spend far more on enabling the addiction over time then they will spend on intervention and treatment. Supporting an addiction or not addressing the addiction is far more costly than any rehab center. When you add up all the expenses for an addiction including housing, medical, legal, food, cash for drugs and alcohol, missed time from work, and opportunity costs that are lost, just to name a few, the cost of the addiction can be 10x greater than the cost of treating it.
Comparing treatment centers
As stated many times, treatment centers are doing very similar curricula and nobody has a cure nor has anyone reinvented the wheel. As an intervention company, what we look for in a treatment center are practices that increase the opportunity of success for the substance user and support the family by listening to their wants and needs. Professionals, family members, and substance users should consider treatment centers with effective clinicians and not ones that just go through the motions and discharge clients at 30 days. Clinicians and rehab centers who take what they were told as honest truth by the substance user and run with it is sadly a common occurrence among clinicians. We look for and see things that are important that you the family and substance user may never see on a rehab centers website nor will you hear it from their admissions person. Here is a list of some of the most important things to consider in choosing the right rehab center:
- JCAHO (Joint Commission on Accreditation of Healthcare Organizations)
- CARF (Commission on Accreditation of Rehabilitation Facilities)
- LegitScript Certification – A thorough vetting process performed to determine eligibility for advertisement online. In order to receive this you have to prove you are a real rehab center.
- Family Involvement – Will the center allow the family to have a voice? Will the rehab center consider the family in the discharge plan? Will the facility only listen to the substance user and not fact check their story with the family who has suffered?
- ROI’s – Does the rehab center make signing a release of information for the interventionist and the substance users family a condition of their stay? Will they allow the family interventionist or family therapist to help them with information they will not receive from the substance user?
- Length of Stay – Is the center equipped to treat clients longer than 30 days?
- Cell phone and electronic devices – Does the center restrict cell phone use and do they have a blackout period for the substance user. The highest risk of leaving AMA (against medical advice) is in the first two weeks. How do they address this?
- Accountability – Are they afraid to challenge the substance user and help them see their role in the destruction that has affected their family?
- Boundaries – Will they work with the family and encourage them to set firm boundaries on relapses, AMA’s and continued recovery efforts?
- Consequences – Will the work with the family to help them understand the importance of implementing consequences in the event the substance user relapses or discharges treatment against medical advice?
- Discharge planning – Is the rehab center willing to go to bat for others that have been affected by the addiction and are they willing to work with the substance user to understand the importance of not returning to the old environment too soon?
Some of these may appear harsh to families. For a substance user going to treatment for the wrong reasons they will be sure to take issue with just about every one of these items. The items listed above help with positive outcomes. The least qualified person to dictate treatment is the substance user and their family. Although there are some clinicians, medical professionals and textbooks who will tell you this isn’t true, in our experience it is. The right rehab center should seek to look at everything and not just go through the motions or look only through the lens of the substance user. Rehab centers that challenge clients to look at things differently and who address the affected family system have better outcomes than rehab centers who do not. This is not an opinion, this is several decades of experience in seeing what works and what does not.
How can family members help?
Families can start off by considering the checklist above when choosing the right rehab center. Families can help by understanding their role in the addiction and how the entire family system is partially at fault for things getting worse. When you only treat the substance user and not their family, you are setting the substance user up for failure. Families are changed in an unhealthy way. They often do not see that much of what they have done and continue to do is counterproductive to the substance user seeking help. Unhealthy family systems have been known to pull the substance user back into the addiction based on its dysfunction. Although this may not be a conscious methodical act, it does happen insidiously. The primary enabler is afraid the substance user will get well and then they will no longer be needed or have a purpose in the relationship. The hero is afraid that if the substance user gets well they will lose their role as the overachiever of the family. The hero also fears that if the substance user gets well and it wasn’t the hero’s idea then how will that justify all their efforts of control up until that point? The martyr is terrified of what will happen to them if the substance user gets well. They are more worried about themselves than the substance user. Some family members often try to sabotage the treatment efforts of the substance user because they were not the one who helped them get better. Guilt and shame of past family secrets often causes this. Families can help by understanding their underlying reasons for acting and behaving as they have and seeing that it has brought them no closer to a solution.
All of these family roles can affect the outcome of the substance user. For a rehab center to not consider this can be the difference between the family having a better life and the family and substance user going right back to the way things were before treatment. One of the most effective things a family can do to help is understand the importance of their own needs for recovery. Self help groups such as Al-Anon, Families Anonymous, ACOA, along with individual therapy, BCT (Behavioral Couples Therapy), and family recovery coaching is a great start. Families can help by understanding they can not help the substance user or themselves by doing the same thing they have always done.
Intervention and support for your loved one and family.
An intervention company that supports the family and collaborates with the center during the substance users treatment stay provides the greatest opportunity for positive outcomes. There are many effective interventionists that accomplish the task of helping someone get to treatment. Unfortunately very few do only that. Family First Intervention has a full staff of coordinators, interventionists and Family Recovery Coaches along with a clinical director to help families through the recovery process. Allowing the substance user to go to treatment again while the family does nothing different will almost always produce similar failures of the past. Our research shows that when we incorporate evidence based strategies to our intervention process and support the family, positive outcomes occur more frequently. We are happy to assist you anyway we can and look forward to discussing your situation with you. We are grateful for the opportunity to hear your story and provide any insight or solutions we can.