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Transitional Recovery

Larry R. Seybold, M.S.
Edgerton, Wisconsin

The approach to therapy is holistic. Both chemical dependency and life dependency are broken, and individuation skills are taught. The treatment has been implemented, is currently functioning, and can function for as few as four adult or eight adolescent clients. That these numbers are small is of particular importance in areas of limited population.

The administration of this program is quite simple. A nonprofit organization is established, and a board of trustees from the community oversees the operation of the facility. Staffing includes a therapist/ administrator, co-therapist (possibly a practicum student), house manager, secretary/bookkeeper, and two to three staff assistants. A community-based residential facility for 8 adults and 16 adolescents is recommended. A 50-percent census will pay expenses. Startup costs should be recovered within 4 years. The program is voluntary: "If you do not like it here, you should leave; you are welcome to return at your discretion."

The clinical portion of the program has one purpose: To promote recovery from chemical dependency. No psychological testing is performed, and psychological issues are not addressed except in the context of recovery. Clients are screened for eating disorders, and those with other disorders of greater priority are referred.

Clients with these disorders may be treated at the facility but only their dependency is treated. This approach eliminates many extra costs. In addition, detoxification is not done at the facility; it is considered a medical process to be completed in a hospital.

Introduction

This paper provides an overview of what transitional recovery is and how it can be applied in areas of less dense population. These areas do not have the volume to support the frills that a high-volume market may support. The focus is cost-effective singleness of purpose.

Treatment Approach

The title of the program, Transitional Recovery, reflects a community-centered focus for the treatment of chemical dependency. This approach involves the community in the treatment to eliminate stigmas and to educate the community in the disease's effects. Transitional Recovery keeps clients in the community while they learn to recover and to build a support system. Other programs often isolate clients, making them feel like outcasts. Transitional Recovery encompasses environmental, family, and individual growth. Transitional Recovery is a holistic approach to the disease. and not just the individual.

Purpose

There is only one purpose to Transitional Recovery: To promote recovery from chemical dependency. This purpose is the "how and why" of its cost-effectiveness. No psychological tests are given; there is no recreational mandate. Problems are referred to the proper sources.

A good example is the detoxification process. Detoxification is a medical process that needs to take place in a hospital setting. Removing the chemical is medical; preventing the relapse and finding sobriety are combined functions of the transitional recovery facility and the community.

The majority of clients had previously received multiple treatments for chemical dependency but found success in transitional recovery because of its

singleness of purpose. The admissions are voluntary. and the vital assessment for admission is "Do you want to help, and why do you want heip?" Clients who only want to regain their driver's license, for example, are turned away. This approach is a key motivation for the community, because only clients who want to recover fronl chemlcal dependency are accepted

Methods and Content

The methods used in Transitional Recovery are to develop a nonprofit corporation that is based on educating the community and providing a family atmosphere to clients who wish to recover from chemical dependency. The original mission limited the population to women, but lack of clients forced a change to coeducational.

The project was instituted in an eight-bed, community-based residential facility. There is a clinical component, an administrative component, and a living skills component designed to allow input from the community. The clinical portion of the program provides a 12-week educational lecture series (table 1), a three-phase behavioral program (table 2), and group and one-on-one therapy; in addition, family therapy is offered. Family therapy is voluntary, but strongly encouraged.

The foundation of Transitional Recovery is a 12-step model. However, the point of view differs from that of other 12-step programs. The focus is not on working the steps but on applying the steps to daily living. Clients study one step per week. During an informal morning group, each client states how, on the previous day, he or she lived one of the steps already studied.

When the program is completed, the client understands the workings of each step and its application. This approach also provides a stable pattern so that the client can follow one step per week into middle and late recovery. This process includes continuing individuation and, later, differentiation .

The lecture series covers a broad spectrum of topics, ranging from early to middle sobriety. The lecture series is an ongoing group into which a client fits depending on the stage at admission. The series allows community participation. community participants lecture in their areas of expertise, and staff members assist the lecturers. Exercises complement this participation For example, each client is given "custody" of a teddy bear for 40 hours and instructed to treat the bear the way the client wants to be treated. Any bear left unattended is confiscated by the staff; clients are allowed to use baby sitters for short periods and are encouraged to play with the bears.

A relapse prevention plan is completed, and group feedback for interventions is assigned. A significant other is then consulted privately. The client reviews the plan and asks that the interventions be implemented. With adolescents, a family contract is mediated and signed. In addition, the family is asked to present a family first step at the graduation group. The content of the two programs is similar.

As table 1 shows, Transitional Recovery includes an extensive lecture series. This series works as well with the public as it does with the recovering population. Many times, the two populations can be combined to the benefit of both. Outside speakers make the series more enjoyable and provide a greater sense of expertise. This approach works as a marketing tool in a small population while also serving the community as a whole.

Behavior Modification Component

The behavior modification component involves three stages. The first stage is primary care, the second stage is median care, and the third stage is community care. The phases integrate the client into the community after a period of stabilization. Each phase lasts 4 weeks and offers specific benefits to the client. The focus is on achievement, not consequences. The consequences are natural; if a client wants to go out on Saturday afternoon, he or she needs to find a sober person from the community to go along. The benefits to the clients include building a support network, asking to have needs met, and discovering that they can do the same things sober as they did when using chemicals.

This approach once again involves the community. Without integration, clients would merely sit around the facility. With adolescent clients, the community volunteers are screened more closely and the times of curfew are adjusted appropriately. In addition, the first phase for adolescents requires a Cooperative Education Student Association teacher or tutor to monitor homework.

As shown in table 2, consequences are not mentioned. This is because the natural consequences will have a stronger impact on the client than any artificial stimuli. All clients must complete the goals, and exceptions are made only with the community's permission.

Three groups meet daily. The first is an informal process-and step group, the second group is a therapy group, and the third is an educational group. (The independent living skills group meets separately from the other three groups.) In addition to the group time, at least one one-on-one therapy session is held per week. These sessions lessen progressively toward discharge. The one-on-one therapy usually starts with a psychological history that includes establishment of attachments, progression of development, and repetitive patterns. Problem solving and exercises are implemented after this information is compiled. Cognitive focusing of the mind, affirmation, inventories, and empty chair are exercises that have worked well.

I.   Phase I Read chapters 2 and D (pp. 58-63) of Alcoholic's Anonymous (Big Book) and step 12 in 12 Steps and 12 Traditions (12x12); discuss with your buddy. Complete first step worksheet. You may not receive or make telephone calls for the first 3 days, but calls may be made when the first step worksheet is completed and approved. You may attend outside meetings with a buddy. Read step 2 in 12x12 and discuss with your buddy. Ask for and complete the second step worksheet. You may have one visitor when the second step worksheet is completed and approved; an approved visitor may be received for 2 hours. You will obtain a temporary sponsor. You may attend 12-step meetings with a buddy or temporary sponsor. Read step 3 in 12x12 and chapter 4 of the Big Book and discuss with your buddy or sponsor. Complete the third step worksheet, express an understanding of spirituality, and volunteer for morning meditation or evening dedication. You may have two visitors for 4 hours when the third step worksheet is completed and approved. You may have a 2-hour pass on Sunday afternoon if your behavior is appropriate. You may attend 12-step meetings on your own (adolescents must attend a prearranged meeting where staff will monitor arrival and departure and return to the facility). Read step 4 from 12x12 and chapter 5 (pp. 64-71) of the Big Book and complete the fourth step. You will start the relapse prevention inventory and be a buddy to a peer. You will discuss reading with peers or a sponsor. You may receive a 4-hour pass. 9 You may lead activities such as the morning stretch and step study groups. You may attend recovery activities with a buddy or sponsor; your curfew is 12:00 midnight for dances and workshops.  II.   Phase II Read step 5 from 12X12 and arrange to complete the fifth step with an outside source such as clergy or a sponsor. Continue to read the Big Book and steps 6 through 8 from 12x12 and discuss with your peers or sponsor. You must continue to work and show progress on a sobriety plan. You may start a job search or return to work (school for adolescents). You may escort peers to outside activities if appropriate (does not apply to adolescents). You may have eight 10-hour passes. You may plan senior members' graduation. You may be a community leader.  III.  Phase III Continue to read steps 9 through 12 in 12x12 and discuss. You will complete a sobriety plan. You will complete and present a relapse prevention inventory to your significant other and request that interventions be taken. You will continue reading the Big Book. You may earn overnight passes with parents or significant other. You may attend outside activities on your own (adolescents must have a signed consent form from their parents). You will attend graduation, which will include the following: A cake Five visitors Good-bye group Affected member's first step

Family Therapy

Family therapy is the single best predictor of outcome, especially with the adolescent population. Adolescent therapy and family therapy focus on the family structure. Alcohol and other drug abuse (AODA) issues must be addressed educationally. Homeostasis and the point of view of the community both must change. The adolescent program may be used to determine whether out-of-home placement is needed in the first 30 days and to provide family therapy to promote the transition process. Participation by the parents is more effective than out-of-home placement, but participation is not always possible.

Often, the parental structure has failed; thus, parental roles need to be reestablished, coalitions changed, and the outside world allowed to enter. In the past, group homes have been used at great expense, which often allows parents to continue an irresponsible lifestyle and thus perpetuate the cycle.

This therapy also addresses an issue that is often ignored by small populations: gangs. When the family structure is strong, the community- provides training and jobs. Gangs do not form. The gang is a response to a failed community and its failure to fulfill the needs of its youth. Adults must provide the leadership.

Adult family therapy works on reestablishing trust with the family. In the adult group, therapy focuses on the consequences of the disease. The therapy examines the methods of communication, education about the disease and its effects on daily living continuing into sobriety, and support groups. The therapy also examines the developmental movement of the family from its point of fixation, its structures, and its explanation. More intensive therapy is needed in later sobriety.

Finally, the most important ingredient is the family atmosphere. Because the buddy system and the independent living skills program are included in Transitional Recovery, clients must depend on each other and help one another for the common good. This approach not only helps to individuate but also teaches skills that break the co dependent need to be taken care of. Transitional recovery allows differentiation to take place over a period of years and thus breaks the chain of dependency.

Independent Living Skills

The independent living skills program may be the best insurance against relapse that a person—especially a single person—has. Many people suffering from chemical dependency do not have the skills to live a life other than survival. Many skills of daily living that nonusers take for granted are foreign to the chemically dependent person. Chemically dependent people are held prisoner because they cannot balance checking accounts, complete tax forms, find sources of help, vote, purchase clothing, budget, shop for food, complete a resume, successfully interview for a job, or obtain a driver's license.

Dependency and fear of abandonment are the biggest motivations in the lives of dysfunctional people. If treatment removes the chemical but does not teach the skills, the chemically dependent person will survive by finding another dysfunctional person to take care of him or her. The cyclical feedback structure of abuse holds the client in bondage.

The community needs to help in all these areas. Community participation allows the client to rejoin the community and allows the community to fulfill its duty. Lasting friendships are made, the community has an investment in the facility, and intolerance fades.

Postprogram Activities

Second, a bridge group is established to bring back graduates. (A 90-day separation period is required to discourage dependence on the facility.) The bridge group participants instill hope and confidence in transitional recovery. Both postprogram activities have played vital roles in the continuing recovery process.

Facility Administration

The head therapist usually functions as both administrator and therapist and, many times, as family therapist. One other therapist is usually needed. (Two therapists are needed for the adolescent program.) A secretary-bookkeeper oversees office management. A house manager teaches and monitors living skills and oversees the maintenance of the facility.

Two or three staff assistants monitor the clients (four or five assistants are needed for the adolescent program). The use of graduate-level interns offers a low-cost, but highly skilled, staffing option. One staff member is also the volunteer coordinator and is responsible for obtaining releases and for recruiting and screening volunteers.

The facility should be able to function on a 50-percent census for adults (or eight adolescents). At this rate, the startup costs are recovered in 4 years. In addition, the community donates funds, dances are held, and services are rendered to encourage community participation and to raise funds. In most cases, the primary source of funding is the county department of social services. Primary care (first 30 days) costs $80 per day. The remaining 60 days cost $65 per day. Billing is completed every 30 days.

The county provides the paperwork in most cases. Costs of operation are passed along to the county in an annual contract that guarantees a minimum entitlement.

In addition, AODA assessment can help the community and the facility raise funds. Local municipal courts, attorneys, the department of transportation, and the department of vocational rehabilitation may need an AODA assessment.

Process notes are recorded in a Document Assessment Plan format, titled, and numbered to coincide with a master problem list. All material conforms to Joint Commission on Accreditation of Hospitals standards. Cases are reviewed weekly. Policy, the backbone of the facility, is reviewed every 6 months by a quality circle.

Findings

The study covered 5 years. Three clients did not complete the program. (One client did not want to comply with the rules; a disruptive client was removed and refused referral to the appropriate psychological source; a third client gave no reason for leaving.) Two clients relapsed postdischarge;

both had discontinued medication and were stabilized within 2 weeks. One client, who had also discontinued medication, committed suicide 1 month after graduation. The remaining clients are sober to this point.

Conclusions

This cost-effective program fits the needs of small communities and can be adapted to larger ones. This "no frills" approach of transitional recovery has a very positive success rate. With health-care funding limited, the choices are 14 days in a hospital setting or 90 days in transitional recovery for the same cost.

Clients who made the most progress were those most lacking in social skills. Many clients found a "family" that they were able to join, separate, and differentiate from, thus allowing them to continue through the developmental process.

Recommendation

A facility of this type should not be owned by an individual, because a struggle for prestige may sabotage the process. Discretion in hiring is of the utmost importance; a person who fills a temporary need may be a burden in the long run. Ask for help; the community is waiting to respond.

This paper is dedicated to Dale Stehno, who gave me the confidence to write again.—Larry R. Seybold, M.S.

Last Updated 11-7-02