VI. Building Support for Abstinence

1. Treatment

This section describes five types of treatment that are currently available for substance users and their families. It is not always necessary to participate in all of these programs, although some individuals may choose to do so.

Figure 1 shows some examples of individual needs linked with appropriate treatment types. For example, if you were to follow the arrows, an alcoholic who is experiencing severe alcohol withdrawal may enter a detoxification program.

Having struggled with prior attempts at maintaining abstinence, this person may then decide to seek the support of an inpatient program to help with stabilization and linkage with recovery services. The opposite may be someone that desires supportive counseling and wants to learn more about addiction and coping skills.

This individual may opt to attend an outpatient program and attend self-help meetings and couples counseling weekly. Here are the five treatment options:

FIGURE 1: INDIVIDUAL NEEDS & TREATMENT TYPES

a. Detoxification:
• A process in which there is a clearing of poisons from the body.
• Changes the body’s physical make-up to help it adjust to the absence of drugs in the system, as well as mental and emotional adjustments to prepare for the next step in achieving and maintaining abstinence.
• The goal of detoxification is to provide safe withdrawal from a substance(s).

b. Inpatient Treatment:
• Inpatient treatment requires the person to live on-site at the recovery program (i.e., hospital or residential center).
• Exposure to a variety of recovery tools including, group discussions, individual counseling sessions, access and participation in 12 step programs (AA, NA), educational programs, and access to medical, legal, family, and psychiatric care.
• The length of stay varies based on program structure, managed care (insurance coverage), and degree of following program rules and policies.
• Many inpatient sites may also offer detoxification services so that there is continuity of care.

c. Outpatient Treatment:
• Outpatient programs provide access to:
o  group processing
o  individual sessions
o  psycho-education
o  linkage to self-help programs
o  referrals for legal and medical assistance
o  some also provide employment assistance
• Daily participation is not required, although many people will attend 2 groups per week, 1 individual session weekly or bi-weekly, and fill in the rest of his or her days with attendance at self-help meetings.

d. Couple/Family Treatment:
Traditionally, treatment clinics and providers have focused on working with substance users on an individual basis. However, working with the substance user and his or her partner or family can result in very positive outcomes for everyone involved.

These programs focus on:
●   Building relationship trust.
●   Increasing support, caring, and positive interactions within the family.
●   Increasing and promoting behaviors that are supportive of abstinence.
●   Improving relationship satisfaction.
●   Teaching and practicing effective communication skills.

e. Self-Help:
• Self-help programs are available in every state and virtually every country.
• There are meetings available daily in most cities.
• Meetings may be held at churches, community centers, or libraries.
• All self-help programs are peer organized and peer driven.
• Some meetings are geared specifically toward the substance abuser (AA, NA), while others are for family members or friends who are struggling and seeking support of their own (Al-Anon).

**More information on self-help is available later in this section.**

2. Triggers and Coping

Achieving and maintaining abstinence can be one of the most difficult challenges for an individual faced with a substance use problem. Each day, there will be times when the person struggles to not use alcohol and/or drugs. It is very common for substance abusers to have urges to use and to be confronted with situations that may trigger the urge to use and moreover, a lapse or relapse.

Lapse and relapse are defined in the section titled: Continuing Recovery: Helpful Guidelines. Sharing these thoughts and feelings may be difficult for the substance abuser, especially in the presence of his or her partner.  In addition, sharing this information may also be met with varying degrees of support from the partner. 

There may be times when the substance abuser reports use for the first time in front of the partner.

Moreover, the non-substance-abusing partner may be very disappointed if there is a relapse or there is difficulty maintaining abstinence. Urges to use are very common as are feelings of anxiety, anger or disappointment at actual use by both the substance abuser and his or her partner. There are steps to ensure that a lapse or slip does not necessarily lead to full-blown relapse. Acknowledging these struggles and accepting these feelings can be helpful in determining the need for additional support (i.e., relapse prevention groups, detoxification, increased involvement with a 12 step group, getting a sponsor, and so forth).

The following helpful hints will be most effective if the substance user AND his or her partner review and discuss them together. The partner can be of tremendous support in helping the substance user identify and avoid triggers, combat urges to use, and identify the need for further help.

a. Urges to Use and Triggers: Helpful Hints

The substance user should ask:

- How often have I experienced urges to use alcohol/drugs?
- What was it about this situation that caused me to crave the alcohol/drugs?
- On a scale from 1-10 (1 = not strong at all, 10 = very strong), how strong is the urge to use?
- Are there certain people, places or things that are related to my urge to use?
- What did my partner notice?

b. Coping and Resistance: What worked, what didn’t?

The substance user should ask:

- What was it about this situation that caused me to use?
    How do I feel about this?
    What support do I need right now to help me get back on the abstinence track?
- What did I do to avoid using?
- Was there a helpful strategy or coping skill that I used that worked?
- How can I reduce the chances of having a lapse/relapse?
- If I did use: - How can my partner help me out?

3. Couple Promises

A strong, satisfying relationship can be a major reason not to drink or use drugs, as well as a source of support for minor lapses.  However, arguments or hard feelings about past or feared future drug use or drinking (or other disagreements) can ultimately lead to substance use. Learning and practicing new skills to handle such disagreements or fears more effectively can serve to reduce the type of stress that may contribute to a relapse or continued use.

A strong, committed relationship also can serve as an important foundation to begin and maintain a sober lifestyle. When a couple verbally commits certain “promises,” they express commitment to their relationship and to strengthening the relationship. Each partner is responsible for keeping the promises that he or she has made. If one partner is unable to keep a promise, this does not relieve the other person from keeping his or her promises. The four promises are as follows:

a. Couples should not threaten divorce or separation: Threatening divorce or separation can greatly interfere with relationship improvement efforts as well as feelings of commitment to the relationship. Threats can be viewed as a manipulation tool used by either partner. Making this promise discourages the use of threats as ammunition during arguments or as a result of overall frustration. making this promise does not mean that separation consideration has to stop. Having said that, the promise is to stop discussing separation at home.

If divorce or separation is a very real concern in the relationship, we encourage the couple to meet together to discuss this with a counselor or mediator. If a couple is committed to working things out, we advise they eliminate threats of divorce or separation in their conversations as one of their promises to each other.

2. Decide on time and place:  Partners should get together privately at a specified time and place where they can talk without interruption for a few minutes. It would be helpful to plan the discussion at an already established event that happens each day, such as at meal-time, during breakfast, after work, at bedtime, etc.

This way, the discussion is more likely to become a part of a daily routine. Remember, choose a time when both partners can devote their full attention to each other without interruption.

3. Routine: Alcohol/drug use is often a very ingrained behavior and it is important to replace this habit with others that support abstinence, including the Abstinence Trust Discussion and attendance at self-help groups, treatment sessions, etc.  The Abstinence Trust Discussion, if used correctly, will begin to be a daily positive interaction that is reinforcing to both partners.

b. Trust Discussion Rules:

1. Not a time to bring up the past.  The Abstinence Trust Discussion is not an opportunity to bring up negative events of the past. This experience can be a positive experience, while reinforcing abstinence. Introducing a negative into the discussion may look like this:

“Thank you for staying sober, but I know this is only the calm before the storm because I have seen this before.”

This sort of comment should be avoided.

2. Honesty is necessary.  If the substance-abusing partner has not been abstinent or is not sure if he or she will stay abstinent in the next 24 hours, he or she should state that AND NOT LIE.  It is important for both partners to be honest with each other when having this discussion.  One of the goals is to build trust, and that won’t happen if both partners are not being honest with each other.

Practicing the trust discussion highlights the simplicity of it and will encourage you and your partner to practice this skill daily. This may feel strange or unnatural at first, but as it is practiced, you will become more comfortable with it.

c. Abstinence Trust Discussion: Substance User

The substance-using partner makes a statement about his or her abstinence over the last 24 hours and his or her intentions for the next 24 hours.

“I have been sober for the last 24 hours and plan to remain sober for the next 24 hours.  I want to thank you for listening and being supportive of my effort to be alcohol/drug free.”
 
d. Abstinence Trust Discussion: Partner

The non-substance-abusing partner might respond by expressing gratitude for his or her partner staying abstinent over the last 24 hours and offer support for the next 24 hours.

“Thank you for remaining sober for the last 24 hours and let me know if I can be of any help to you during the next 24 hours.”

The discussion between partners will look something like this:

Substance User 
“I have been sober today and plan to be sober for the next 24 hours.  Thank you for listening and being supportive of my efforts to be drug and alcohol free.”

Partner
“Thank you for remaining sober for the last 24 hours and let me know if I can be of any help to you during the next 24 hours.”

5. Self-Help

Self-help programs, like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), are made up of groups of men and women who share their experiences, strengths, and hopes with each other in an effort to combat their common problem and help others recover from alcohol/drug dependence.

●   The only requirement for membership is a desire to stop drinking or doing drugs.
●   There are no dues or membership fees.
●   Self-help programs of this nature are not aligned with any political, religious, or social organization or institution; they do not endorse nor oppose any cause.
●   The primary purpose of self-help is to achieve and maintain abstinence as well as assist others in their recovery.
●   Acknowledgments are extremely important; coins, key chains, and celebrations of abstinence are examples of ways that recovery milestones are acknowledged and celebrated.

For more information: Alcoholics Anonymous: www.alcoholics-anonymous.org or Narcotics
Anonymous: www.na.org

COMMON SELF-HELP TERMS:

a. The 12 Traditions:
• The 12 Traditions are principles that are adopted by the membership of AA/NA.
• These documented principles cover topics like anonymity (i.e., respecting each other’s confidentiality), membership, and independence.
• They are the foundation on which the program was built and the framework that allows the program to continue.

b. The 12 Steps:
• The 12 steps are the heart of self-help recovery programs.
• These steps outline the principles and practices that the founders of AA found to be helpful in achieving and maintaining abstinence.
• The steps are not a formal or necessary code to the goal of abstinence, but a process guideline that substance abusers can use to help in their recovery program.
• Newcomers are not asked or required to follow these steps, but to keep an open mind.

c. Higher Power:
• A higher power is not necessarily religious, but it can be.
• The higher power is one chosen by the individual.
• The idea is for the individual in recovery to have a spiritual relationship with a higher power.
• This relationship can assist the individual in letting go of unhealthy, hurtful baggage and in gaining acceptance of his or her problem.
• Belief in a higher power can help promote acceptance and understanding that everything is not in control the control of the substance user, but part of something larger.

d. Sponsor:
• A sponsor is someone who is also a member of the group, who the substance abuser asks to ‘sponsor’ him or her in his or her recovery program.
• While a sponsor can be a close friend, he or she also can be someone who can help the substance abuser through the 12 steps, attend meetings with, discuss struggles and accomplishments with, and to call when things are difficult.
• A sponsor can change based on the needs of the individual in recovery.

e. Home Group:

• A home group is a meeting that is attended frequently and consistently.
• The substance user may have an active role in its continuing (collect small fees for coffee, getting materials/brochures, finding space to hold the meeting).
• This meeting is where the substance user holds celebrations for recovery achievements.

6. Medications

The use of medications can have a significant role in assisting substance abusers with achieving and maintaining abstinence. The use of medications can also assist the substance abuser in the recovery process, but is by no means a ‘magic bullet.’ Taking the prescribed dose of medication can be a key problem; the substance abuser must be monitored by a physician and should be participating in additional treatment components.

Medications can decrease withdrawal symptoms, reduce cravings, provide stabilization for the return back to daily routines and meet family and/or employment obligations, as well as decrease or address initial depression and/or anxiety during detoxification and the early stages of achieving abstinence.  Medications can be a most useful tool in helping substance abusers live drug-free lives.

NOTE: Medications of any kind should always be supervised by a physician AND should never be stopped or taken in combination with other drugs without first speaking with a physician. Further, dosage should not be altered, unless physician approved and supervised.

a. Naltrexone:
• Originally used as a tool to block the effects of heroin.
• Naltrexone has been shown to reduce cravings for alcohol, thereby reducing the number and length of relapse episodes.
• Naltrexone is taken daily.

b. Disulfiram (antabuse):
• Taking this medication will make people very sick if they drink alcohol while taking it.
• Disulfiram must be taken daily.

c. Methadone:
• Methadone is used to help ease the symptoms of heroin or opiate withdrawal.
• Methadone is taken daily and is supervised by a hospital or outpatient clinic that is federally licensed as a methadone clinic.

d. Other Medications:
• These medications help to reduce anxiety, difficulty sleeping, irritability, and depression that are often associated with early stages of gaining abstinence.
• Examples include Zoloft, Prozac, Celexa, Xanax & Wellbutrin.

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See more of this publication at Sobriety: A Couple’s Workbook

Learning Sobriety Together: A Couple’s Workbook is also available as a pdf download – see list of manuals on the Addiction and Family Research Group site
http://addictionandfamily.org/