Recovery Support Groups and Continuing Care
The research literature supports the belief that the longer patients are in a treatment system the better the outcome and what follows discharge from primary treatment for addictive disorders may have a greater impact on recovery than the treatment itself (Hubbard, Craddock, & Anderson, 2003). When considering addiction as a chronic, relapsing brain disease, this makes sense. For example, a diabetic who is successfully treated for acidosis or insulin shock has now had the acute phase of his or her chronic disease stabilized. However, without ongoing treatment—including self-management, monitoring, and physician follow-up—it is predictable that the patient will suffer a reoccurrence of the blood sugar maintenance problems and/or develop conditions that result from the disease such as cardiac problems or the need for amputations. Addiction is very similar.
There are basically three types of postdischarge care:
- Continuing care for the addictive disorder
- Attendance and involvement with addiction recovery groups
- Treatment of co-occurring medical or mental health problems and social support services
Please notice that the first one is referred to as “continuing care” and not “aftercare.” The reason for this is twofold. We are in fact talking about maintenance of recovery from a chronic illness, but even more importantly, a reasonable question that a patient might ask is, “Why should I go to aftercare after I have been treated?” Continuing care models may include senior peer-directed groups or counselor-led outpatient treatment, often reimbursable by health insurance.
Recovery Support Groups
Attendance and involvement with addiction recovery groups sometimes create dilemmas for clinicians. Let me first identify my bias for Twelve Step recovery groups. In my clinical experience, I have found these to be most effective and there is no question about their availability. However, just as the gold standard in treatment is individualized treatment, we need to be pairing patients with the type of recovery group most attractive and appropriate for them.
Even if AA and NA are most effective, they will not help the patient who will not go to meetings. A common reason for refusal to attend is “all that God stuff” which for some patients may stem from their early life experiences or their current status as agnostics or atheists (Alcoholics Anonymous, 1976), although being an agnostic or atheist is not an obstacle to working Twelve Step programs. For others who are not yet ready to change, the supposed opposition may have more to do with “all that sobriety stuff.”
I recall early in my career that if a patient still in primary treatment refused to attend AA after discharge, they were administratively discharged for noncompliance. There are also recovery support groups for patients with co-occurring disorders, including Dual Recovery Anonymous and Double Trouble. While some clinicians may prefer the patient to attend Twelve Step recovery groups, attending alternative support groups or systems is preferable to not being involved with any recovery support group at all.
Among the non-Twelve Step recovery support groups is this author’s preference for Self-Management and Recovery Training, also known as SMART Recovery, although it has two disadvantages. It requires a cost for attendance and it is not nearly as commonly available as AA. Other recovery support groups include Secular Organizations for Sobriety (SOS), Women for Sobriety, LifeRing Secular Recovery, and Rational Recovery, which some clinicians perceive as having a bias against Twelve Step programs.
There is some thought that Twelve Step recovery support groups may appeal more to people with an external locus of control while more cognitive-behavioral groups such as SMART Recovery and Women for Sobriety may hold more appeal to individuals who have an internal locus of control (Horvath, Misra, Epner, & Cooper, n.d.).
In addition to the Twelve Step and non-Twelve Step programs, there are religious-based programs such as Jewish Alcoholics, Chemically Dependent Persons, and Significant Others (JACS) and Christian programs including Celebrate Recovery and Reformers Unanimous International which might be particularly appealing to those who have gone through a Christian-based primary treatment program.
There are also online support groups and chat rooms for addiction and recovery which may be particularly helpful for individuals who cannot attend in-person meetings. These individuals include those in the deployed military and/or those who are geographically isolated.
The third type of continuing care is for treatment of co-occurring medical or mental health problems and need for social support services such as educational services, vocational training, and/or employment. Clearly, these services would be determined by the individual patient’s needs.
I would like to close with a case example that supports the view that the important concern is the outcome, not the journey. A sixty-four-year-old African American male who had lived in rural Alabama all of his life and made his living as a truck farmer, relocated to Columbus, Ohio and obtained a job working in a manufacturing plant. After about two years on the job, his supervisor suspected that he had a drinking problem and sent him for an assessment. He did in fact have a problem and he was admitted to an inpatient treatment center. Throughout his treatment when told that he had a disease, he protested, saying that it was a moral failure on his part. When urged to go to AA, he declined and said that all he needed was to go back to church. When it became obvious to the staff that his beliefs were unshakeable, they arranged a meeting with the patient, the pastor of his church, and his family and the staff designed an entire continuing care program around his church.
Clearly our approach should be “different strokes for different folks.”
Alcoholics Anonymous. (1976). We agnostics. New York, NY: Alcoholics Anonymous World Services.
Horvath, A. T., Misra, K., Epner, A. K., & Cooper, G. M. (n.d.). Personal responsibility and locus of control. Retrieved from http://www.centersite.net/poc/view_doc.php?type=doc&id=48357&cn=1408
Hubbard, R. L., Craddock, S. G., & Anderson, J. (2003). Overview of five-year follow-up outcomes in the drug abuse treatment outcome studies (DATOS). Journal of Substance Abuse Treatment, 25(3), 125–34.
McKay, J.R., Alterman, A. I., McLellan, A. T., & Snider, E. C. (1994). Treatment goals, continuity of care, and outcome in a day hospital substance abuse rehabilitation program. American Journal of Psychiatry, 151(2), 254–9.