—by Paul M. Kubek
Jane feels a bit annoyed whenever she hears fellow classmates at the community college she attends make judgmental comments about people who abuse alcohol and other drugs. After all, she and her classmates are studying to be chemical dependency counselors and social workers. They should be learning how to convey acceptance. It is the foundation of a working alliance—the safe and trusting relationship—that is necessary to support people through recovery. Judgmental language is not safe. It is aggressive. It puts people on the defense and inspires counter-attack or withdrawal or any number of self-protective maneuvers.
Jane is sensitive to judgmental language, because this is what she had expected to receive from service providers when she started her own recovery journey in the spring of 2004. However, to her surprise and relief, this is not how she was treated. She received patience, acceptance, and the persistent reminder that a relapse to her substance use was probable but not inevitable and certainly not a reason for termination from treatment—ever. She insists that this disposition saved her life. She has not used alcohol or other drugs for a year and a half.
Jane does not react against judgmental language whenever she hears it fired in her direction or ricocheting around a room. First, she reflects upon the words, upon the people from whom the language has emerged, and upon herself—her own thoughts and her own feelings of disappointment. She reminds herself that her classmates may not have firsthand experience with substance abuse and recovery, and that they may, in fact, be struggling to understand it. She reminds herself that her ability to observe and to convey acceptance are the skills that will make her the kind of professional she wishes to become. It is her way of "giving back," of acknowledging the spirit of the people who work for the Integrated Dual Disorder Treatment (IDDT) SAMI Reentry Program at the Scioto Paint Valley Mental Health Center (SPVMHC) in Greenfield, Ohio—the program that helped her save her life.
Jane is twenty-one years old.
Isolation: Before Recovery
In the spring of 2004, Jane was arrested and sent to a county jail. She does not describe the behavior that resulted in her arrest, except that it was the result of using drugs. She does not name the drug either: she refers to it only as "her drug of choice." For this version of her story, there is no need for any more details, because this story is less about what happened before the arrest and more about what has happened since.
However, Jane does share the following information to set the context of her recovery. She started using her drug of choice as a junior in high school. Back then, it did not stop her from being a good student and a reliable friend, but over time, it eroded her ability to concentrate and her ability to maintain trusting relationships with others. After she graduated, she increased her use of the drug. She dropped out of two different colleges because she could not stay focused. She fought constantly with her family, moved in with a friend who also used drugs, and eventually got fired from her job. Then she got arrested. A week later, her parents posted bond.
"When I got out, I realized that I was not where I wanted to be in my life," Jane says. "I was not living a full life. I was living my life for a drug. When you're using, you don't pay attention to details. You're focused on one thing—getting that drug. You don't see the clouds in the sky, the season changing, the rainbows. I see all of that stuff now. I see the colors. I pay attention. My life has changed 180 degrees since I have been involved in the SAMI program.
Acceptance & Social Support: Recovery Begins
In retrospect, Jane's arrest was an external event that inspired an internal change which aligned her with people in her life and in her community who were willing to help. When she was arrested, her parents placed telephone calls to close friends. One of those friends connected them with an acquaintance at SPVMHC, who connected them with SPVMHC's
After her release from jail, Jane made an appointment with the SAMI Re-entry Program and two weeks later, she went there for an interview—to see if she met the eligibility requirements. The program serves people with co-occurring mental and substance use disorders between the ages of 17- and 30-years old who are involved with the criminal justice system. Jane was diagnosed with depression and substance use disorder.
"I was expecting to go to an office once or twice a week and be shuffled in and out," Jane recalls. "Instead, they helped me realize I wasn't the only person going through this. The people at the SAMI program were so accepting. They told me that with my drug of choice, I might relapse. They told me that if I do relapse it does not mean I am done.
"When I realized I could get help and I wasn't going to be judged or looked down upon—that they would accept me for who I was and that I would be able to see the colors in the world again—I decided to keep going. I wanted to change my path. It relieved me that I did not have to be this way any more."
Working Alliance & the Interpersonal Environment
The IDDT model is built upon 14 core components (see below). Two of these components can be detected in Jane's narrative without her having named them specifically. These are stage-wise interventions (stages of change and treatment) and motivational interviewing. Both of these components help service providers create the interpersonal environment of acceptance to which Jane refers (see Connors, Mueser, and Miller in Resources on page 7d). There are six other components of IDDT that Jane specifically describes as being helpful to her. For instance, in the engagement and persuasion stages of treatment, a case manager at the SAMI Re-entry Program conducted assertive outreach with her and her family by making weekly home visits. She explains that the visits helped her feel understood: the case manager made the effort to come to her and her family and took an interest in her environment. (Although SPVMHC offers family psychoeducation groups—another component of IDDT—her family chose not to attend. They conducted their own research about Jane's diagnoses as soon as they learned about them.)
Jane also participated in group treatment, namely, persuasion groups, which were lead by another service provider at the SAMI Re-entry Program. She describes the group work as an informal, comfortable atmosphere that helped her address her substance abuse (see Persuasion Groups in Resources below). She also benefited from access to comprehensive services and substance abuse counseling, namely, by working with the case manager and with a counselor in one-on-one therapy. She describes the counseling as particularly helpful, because it has given her the chance to talk about important, private issues that she is not comfortable sharing with her parents.
Jane currently sees her therapist once every two weeks and will soon be attending a wellness group, which is part of the active treatment and relapse prevention stages of treatment. Her continuing connection with service providers at the Re-entry Program is evidence of the time-unlimited services component of the IDDT model. Jane has also been working with a psychiatrist about medication issues: this is the pharmacological-treatment component of IDDT.
During the early stages of treatment, Jane dedicated most of her time to individual and group therapy. She did not enroll in the community college until a few months later; however, she applied for her old job and was rehired. She prints promotional tshirts for a local small business. "My boss brought me back after I got out of jail," she says. "He realized that I was in a bad place before but that it did not make me a bad person. It gave me something to do when I got out. It helped me keep my focus off of using."
Jane currently combines a part-time work schedule with full-time studies. She is currently in her second year at the local community college and will attend a third year to complete an internship in substance abuse counseling. This fall she attended classes four days per week and worked 25 hours per week. Since her release from the county jail, she has been living at home with her parents and her younger brother. She explains that her relationships with them have greatly improved.
"When I was using, I would come home every two to three weeks for two to three hours," she says. "There was always screaming and yelling. Now, my dad tells me every morning, ‘Remember how great you are doing.' Even before using, I did not have this kind of relationship, this kind of bond. My parents know it's been a hard road."
When asked to explain what makes her feel good about her life right now, Jane does not hesitate to admit that she is enjoying school, work, and her relationships with family and friends. She no longer feels stuck.
"I am working toward my future," she says. "I am doing things that I was not doing before. When I was using, my life was about here, now, this instant, this drug. Today, I am looking down the road to see what's coming."
Challenges: A Changing Identity
There is a truth about human emotions that is often unstated in day-to-day experience: the truth is that each of us can and does experience many different feelings at the same time. Thus, Jane feels pride and joy about her recovery. Yet, at the same time she also feels some confusion. Her biggest challenge right now, she reports, is self-acceptance.
"I want to stop feeling guilty, to stop being mad at myself," she says. "I know I have faults. No one is perfect. I sometimes hear other people's opinions of me, and it's hard to deal with that, and I sometimes feel what's the point of being clean [sober]. So I have to accept myself. I have to accept what I've done, that I am recovering, that I have the strength to do this. I am trying. What I have done is part of who I am, but it does not make me who I am."
There is another challenge that confronts her, she explains. It is related to her diagnoses. When she started the Re-entry Program, she was diagnosed with depression. Then, it was changed to bipolar disorder. Her new psychiatrist is not sure if she experiences symptoms of bi-polar disorder or if her symptoms are the result of her drug of choice or the result of the psychotropic medication that she takes. Her psychiatrist is working with her to sort this out. The first step is to reduce the dosage of her meds.
"Does this mean I don't have a mental illness or does it mean my body is coping?" she asks. "I haven't decided where I stand on this. The changing diagnosis confuses me. It's hard enough accepting the fact that there's something wrong. It does create confusion. Talking about it is confusing."
Advice: Create Opportunities For Hope
The joys and challenges of Jane's recovery are evidence of the complexity of the journey. They are also evidence of the power of human relationships to support the process of change. Jane does not hesitate to explain that she needs the continuing support of other people. In other words, she needs time-unlimited access to the acceptance that she first felt in the spring of 2004.
"I need support, definitely," she says. "I would not be where I am if not for the support of my family and friends and counselors. I know there is a possibility that I could slip back: once an addict always an addict. But this does not mean I will slip back. As long as I remember the pain it caused my family, my friends, and myself, this will help keep me from falling back."
Jane has advice for service providers in mental health and chemical dependency programs that is based upon her experience. She encourages them not to give up on their clients and their clients' abilities to recover. She also encourages service providers not to be judgmental.
"I've heard horror stories about the way some people have been treated [in other programs]," she says. "It put them in a position of shying away from professional help. A judgmental provider can cause extensive damage. Their clients might wait years to get help again."
Jane also offers words of encouragement to people who experience mental health and substance abuse symptoms but do not seek treatment.
"Get help," she says. "You cannot control the addiction yourself. Your brain has made this drug a part of itself. Once you get help, don't give up. A relapse is just a U-turn. If a relapse occurs, take the step and admit it. Then you can turn yourself around again."
IDDT Core Components
IDDT promotes ongoing recovery from co-occurring disorders among consumers by providing service organizations with specific strategies for delivering services. The implementation of integrated treatment facilitates the following simultaneously: service system change, organizational change, and clinical change. IDDT is built upon the following core treatment components:
- Multidisciplinary Team
- Stage-Wise Interventions (stages of change, stages of treatment)
- Access to Comprehensive Services (e.g., residential, employment, etc.)
- Time-Unlimited Services
- Assertive Outreach
- Motivational Interventions
- Substance Abuse Counseling
- Group Treatment
- Family Psychoeducation
- Participation in Alcohol & Drug Self-Help Groups
- Pharmacological Treatment
- Interventions to Promote Health
- Secondary Interventions for Treatment of Non- Responders
- IDDT Overview
- Kim T. Mueser, Douglas L. Noordsy, Robert E. Drake, and Lindy Fox. 2003. Integrated Treatment for Dual Disorders: A Guide to Effective Practice.
- Gerard J. Connors, Dennis M. Donovan, and Carlo C. DiClemente. 2001. Substance Abuse Treatment and the Stages of Change: Selecting and Planning Interventions.
- William R. Miller and Stephen Rollnick. 2002. Motivational Interviewing: Preparing People for Change (Second Edition).
- Persuasion Groups promote recovery. SAMI Matters newsletter, Fall 2005, p.8-9.
Paul M. Kubek, MA, is director of communications at the Ohio SAMI CCOE.