You Want Me to Commit to Abstinence…Forever?

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You Want Me to Commit to Abstinence…Forever?

By J.P. Foster 10/15/15

Taking the AA abstinence approach one “step” at a time

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You Want Me to Commit to Abstinence…Forever?
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When a client in early recovery, still reeling from the deleterious impacts of substance misuse, commits to a lifetime of abstinence, what is really happening? Are such clients actually able to fathom, at that early point, the meaning of “forever abstinent”? Whether or not they are, we know from clinical experience that most clients who strive for a lifetime of abstinence fail to achieve that goal in any particular treatment episode, thus establishing a likely moment of treatment failure, disappointment, guilt and other negative repercussions when relapse occurs. For these reasons, J.P. Foster takes a different approach, asking clients to commit to brief periods of abstinence that hopefully set the stage for a longer-term recovery. His article also highlights a caring and creative young therapist grappling with his own assumptions about addiction and his approaches to treatment…Dr. Richard Juman

One of the earliest stumbling blocks to abstinence-based treatment is that the client, often still reeling from the impact of long-term substance misuse, is asked to make a commitment to an extended, if not permanent, period of sobriety. For the individual just entering treatment, in very early recovery, the anxiety of giving up their “relationship” with alcohol, cocaine, opioids or another drug of choice can be extremely frightening. For many, the relationship to the drug has, unfortunately, become the longest-lasting and most significant one in their lives. Drug use always carries meaning and may have served an important function with respect to helping the client maintain their psychological equilibrium. So the dilemma faced by these individuals is powerful: “Do I continue to use, because it’s the more comfortable, familiar route, and the drug has been playing an important role in my life, or do I face the fear of sobriety and life without the use of substances?” The commitment to participate in treatment and honestly move towards sobriety is a huge hurdle for any individual. 

I frequently encounter clients who have a brief, early-treatment “honeymoon” with the idea of abstinence. After all, there is usually clear and recent evidence that the clients’ relationship to drugs is having an awful impact on their lives. Often individuals verbalize excitement when admitted to treatment and readily agree to a “total abstinence” policy while in treatment. However, after a short time, the excitement frequently fades and anhedonia sets in, leading to a reversal in their original commitment to total abstinence. One client who was admitted to IOP for problematic drinking confidently stated that: “Not drinking for 8 weeks will not be a problem!” A week into treatment, though, he tested positive for alcohol, then insisted that he didn’t have a problem with drinking. Another client, self-described as “gung-ho” about entering treatment, proudly discussed being sober from all substances and recounted her sobriety dates for each. A couple of weeks into treatment, and several positive drug screenings later, she elected to discharge and pursue recovery/sobriety through other avenues. The excitement of treatment and early sobriety can fade rather quickly. 

Individuals entering treatment often experience a sense of excitement, and that enthusiasm is often mirrored by the experience of their friends and families: “Finally, they are getting help! We’ll never have to face this again!” Or so they think! Here comes the inevitable, often avoided question: “How long is this going to last?” Family members, especially those new to treatment, sobriety, or the recovery process, yearn for a lifetime commitment to sobriety by the client.

A commitment to lifelong abstinence is often more than clients are honestly willing to make, and may not be able to even comprehend. Who can honestly fathom what a lifetime of anything will be like? So I take a different approach: My philosophy is to encourage individuals to commit to one year of sobriety. For the individual seeking treatment, this can seem like a decade. For the family, it can seem like tomorrow. Families of those affected by substance misuse rarely receive the intense treatment that the identified patient receives. In my experience, many families only receive the brief therapy provided by treatment centers or outpatient programs. One spouse questioned me: “How do I handle this after one year? What about day 366? What then?” My advice to her was to start her own therapy process immediately, to understand her own path, to learn more about addiction and how she could change her approach to her husband and other aspects of her life. It’s important that families receive guidance from clinicians about the importance of receiving their own therapy, so that they can prepare themselves for potential relapses or the end of a commitment to sobriety by their family member. Couples or family therapy is also strongly encouraged so that clients and their partners or families become stronger together.  

There are some individuals entering treatment who are genuinely and inherently yearning for lifetime sobriety. I find that individuals who make a quick commitment to long-term (lifetime) sobriety are often middle aged (35+) and dealing with significant problems related to their drinking/drug use. Very quickly in the treatment process, usually after they realize that they can live without substances, they make a commitment to long-term or even lifetime abstinence. Individuals who are married, with children, careers, or significant legal problems often see the advantages of long-term sobriety. On top of those factors, a maturation or “aging out” process may also be operational: Drinking and drugging just isn’t as "fun" anymore, and the recovery from episodes of drinking and using hurts more and takes longer to recover from when a person hits middle age. 

In my experience, trying to “convince” a client that they need to make a lifetime commitment to abstinence may be counterproductive, only serving to heighten anxiety. This is particularly true when working with young adults (ages 18-23+) who present their own set of challenges around commitment to sobriety. In the United States, turning 21 is a rite of passage, and the age at which young adults can drink legally (Let’s face it, most are drinking before they turn 21, but nonetheless, being of age is a milestone.) In my work with one family, the client’s parents nearly fell out of their seats when I suggested the young client commit to only a year of sobriety. The family couldn’t believe that I was not insisting that their son commit to a longer, permanent commitment. But it is frankly ridiculous to believe that a young adult is going to be able to make a meaningful commitment, much less achieve, lifetime sobriety. It is much more reasonable to look at a timeframe that can be easily grasped. For example, I encourage most young adults I work with to make a commitment to remain sober until they graduate from college. Even this can be seen as overreaching. Learning how to handle life’s normal up-and-downs, while going through a natural maturation process, allows an individual time to re-evaluate their issues with substances and the potential need for an extended period of sobriety.

Is a long-term or lifetime commitment to sobriety realistic or even applicable to all individuals? Well, it depends. It seems that the idea of “lifetime sobriety” is a byproduct of AA and also of Jellinek’s “disease model” of alcoholism. A quick search of the Alcoholics Anonymous Big Book finds this passage:

 “….We have seen the truth demonstrated again and again: ‘Once an alcoholic, always an alcoholic.’ Commencing to drink after a period of sobriety, we are in a short time as bad as ever. If we are planning to stop drinking, there must be no reservation of any kind, nor any lurking notion that someday we will be immune to alcohol.” (Page 33)

The Basic Text of Narcotics Anonymous states: “We can never fully recover, no matter how long we stay clean,” (page 84) and also, “Complete abstinence is the foundation for our new way of life.” (Page 89)

If one subscribes to the abstinence models posited in 12-step recovery, lifetime sobriety is the only option. One client, who presented with a 20-year history of problematic drinking was slowly breaking through layers of denial and seeing the destruction alcohol was causing in his life when he presented for treatment. Eventually, he committed to a short-term period  of sobriety (8 weeks). Over time, though, as he completed his treatment program, he began attending (and participating) more in 12-step meetings. Over the next few months, he obtained a sponsor and began working the 12 steps of recovery. Eventually, he made a long-term (lifetime) commitment to sobriety.  

The problem with 12-step ideology related to sobriety is that there is no gray area or middle ground. A person is either sober or not, either/or, even if their level of use isn’t consistent with problematic use. Everybody who enters treatment presents with a different level of substance misuse, and there can be many paths to recovery. But from a 12-step perspective, any use is problematic and anything short of permanent abstinence is seen as failure, even the person who seems able to successfully able to moderate their use. 

The “disease model” or “medical model” reinforces this idea of a lifetime problem. By analogy, if a person is diagnosed with cancer, receives treatment and is in remission, they are still viewed as likely to have a flare-up of cancer again. If an individual has type I diabetes, they need insulin injections throughout their lifetime. However, some type 2 diabetes can be controlled with diet and exercise, but there remains that lingering possibility of the problematic diabetic condition returning or worsening. In the same way, when a person is labeled in 12-step recovery as an “alcoholic” or “addict,” they are seen as having a lifetime problem. This view may not be fully accurate for many people.

Is a commitment to lifetime sobriety encouraged or acceptable for many individuals? Of course it is! As a clinician, I encourage individuals to set both short- and long-term sobriety goals. But here is why I don’t push individuals to make a lifetime commitment to sobriety when they are still in early recovery.

First, setting realistic short-term sobriety goals builds self-efficacy, one’s belief that they can become and stay sober for short lengths of time. The passing out of “chips” at 12-step meetings for 30, 60, 90 days, etc., reinforces positive short-term gains made in sobriety. Asking for a six month or one-year commitment to sobriety seems more achievable and less anxiety provoking for many individuals. 

Second, by setting realistic goals helps family members remain “on guard.” Family members, especially those who haven’t dealt with substance misuse issues in the past, are often naïve about short-term positive gains. They often firmly believe, and are often convinced by those seeking treatment, that the individual will change and there isn’t a need to worry about a relapse. I caution families to be on the lookout for early warning signs of relapse. When family members understand that those seeking treatment are only committed to sobriety for a relatively brief period, they may remain more actively involved in the recovery process and therefore hopefully seek the support they need in dealing with a relapse, should it occur.

Third, short-term goals help diffuse levels of shame. Individuals mired in alcohol or drug misuse battle through thick layers of shame. Set-backs in early sobriety happen quite frequently, and these episodes can be effective learning experiences when coupled with a heightened focus on sobriety. Layers of shame are easily reinforced when a person fails to live up to a standard few will achieve (lifetime sobriety). Encouraging individuals to set, and hopefully achieve, short goals not only builds self-efficacy, but also begins chipping through walls of shame.

Short-term sobriety commitments set individuals up for success in both early and long-term sobriety. Maintaining short-term commitments are obviously more achievable than longer-term vows. Setting oneself up with a potential unrealistic expectation, may fuel additional shame and send a person right back to more prolonged substance misuse. Implementing a system of short-term goals builds over time to long-term gains and this is also true with commitments to sobriety.

James P. Foster, LMSW, LCDC facilitates an Intensive Outpatient program for North Park Counseling Associates in Dallas, Texas. Mr. Foster graduated from the University of Texas at Arlington in 2012 earning an MSSW, with thesis.

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James P. Foster, LMSW, LCDC facilitates an Intensive Outpatient program for North Park Counseling Associates in Dallas, Texas. Mr. Foster graduated from the University of Texas at Arlington in 2012 earning an MSSW. You can find him on Linkedin.

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