Programs for Recovering Alcoholics in Aftercare
People with moderate to severe alcohol use disorders as diagnosed by the American Psychiatric Association’s diagnostic criteria in the DSM-5 will often initially become involved in an acute rehabilitation program. Such a program may consist of initial withdrawal management (medical detox), and very structured and supervised inpatient treatment, residential treatment, or intensive outpatient treatment, consisting of long and intense therapy sessions and other forms of active treatment involvement. Withdrawal management programs and other inpatient or residential rehabilitation programs can last 30, 90, or 120 days, or longer.
These acute and extensive rehabilitation treatment programs are designed to help the individual withdraw from alcohol, learn the basic principles of recovery, and develop a formal plan to follow once they are released from the program. Even individuals participating in residential treatment programs for more than 120 days need to become involved in aftercare programs once their structured rehabilitation program has been completed.
The Importance of Aftercare
People who simply go through withdrawal management and complete a rehab program for an alcohol use disorder or any substance use disorder are not “cured.” Instead, they have simply completed the initial stages of their recovery. There is no cure for alcoholism or any addiction. The goal of the rehabilitation program is to give clients tools to help them engage in abstinence and recovery on a long-term basis.
Once an individual leaves an acute rehabilitation program, they will face numerous challenges and temptations, and they will experience various personal setbacks that can lead to relapse. Aftercare programs are designed to give individuals ongoing assistance and continued instruction, and to provide support to enhance their chances of experiencing a successful long-term recovery.
Despite all the tools available for individuals who are being treated for substance use disorders like an alcohol use disorder, the probability that an individual will engage in a successful program of recovery without a relapse is actually less than 50 percent in many cases. For instance, the National Institute on Drug Abuse (NIDA) reports that relapse rates for individuals who are in active treatment programs is actually relatively high (nearly 40-60 percent in most cases).
NIDA and other sources, such as the American Association of Addiction Medicine (ASAM), report that individuals who simply complete acute rehabilitation programs without engaging in aftercare programs relapse at rates that are nearly 100 percent. These observations have led to the notion that relapse is part of recovery, and individuals who are in active recovery programs and suffer a relapse have a far better chance of dealing with the relapse, getting back on their recovery program, and moving forward with a decreased probability of additional relapses than individuals who are not in an active recovery program, such as an aftercare program.
Many treatment programs now use an individual’s experience of a relapse as a chance to help the individual learn to become stronger, even though the goal of the program is to avoid relapse. Thus, becoming involved in an active aftercare program following completion of an acute rehabilitation program for an alcohol use disorder is an essential component to ensuring one will have a solid chance at long-term recovery.
What Type of Aftercare Programs Are Available?
According to professional sources, such as the textbook Treating Substance Use Disorders: Theory and Technique, an aftercare program is a long-term program of continued treatment that is used following completion of an acute phase of treatment for a substance use disorder. As mentioned above, these programs allow individuals to get past many of the setbacks, including relapses, that occur once they complete acute rehabilitation programs; however, NIDA reports that less than 50 percent of individuals with substance use disorders who complete acute rehabilitation programs follow up with competent aftercare programs.
A solid aftercare program should include several different components. Some that are often essential to aftercare treatment include:
- Substance use disorder counseling or therapy: Generally, individuals in acute rehabilitation programs will undergo counseling or psychotherapy for their alcohol use disorder. The use of therapy or counseling in the treatment of any substance use disorder is the single most important component of the recovery program. Continued participation in therapy is essential because individuals are never “cured” from an alcohol use disorder but considered to remain at some stage of the disorder (e.g., in remission) even if they have not used alcohol for years.
Continued participation in therapy helps the individual to strengthen their overall relapse prevention program, fine-tune their program to face daily challenges, and address setbacks that will inevitably occur as a result of living in the world. Therapy can be performed on an individual basis (one client with one therapist), in groups (one or more therapists treating more than one client at the same time), or via a combination of individual or group sessions (probably the best alternative if this is practical for the client). Group therapy can consist of a group composed of an individual’s family members, others in recovery for alcohol use disorders, or simply the individual and their partner (marital therapy). All of these types of interventions have empirical evidence to support their use.
- Medically assisted treatments: In addition to participating in some form of structured alcohol use disorder therapy, the individual should also continue any medical interventions that have been used during the rehabilitation stay. This can include the use of medications to deal with cravings for alcohol, medications for co-occurring mental health disorders, and/or medications for comorbid medical conditions. Medical interventions alone are not sufficient to constitute a full aftercare program, but when combined with therapy, they help to support the overall aftercare program.
- Treatment for co-occurring disorders: A large number of individuals who have been diagnosed with an alcohol use disorder will have a co-occurring mental health disorder that also needs to be treated. The treatment for these co-occurring conditions can begin in acute rehabilitation programs and should continue as part of a successful aftercare program. Treatment for co-occurring disorders can include additional psychotherapy, medical management, and other supports, such as speech therapy, vocational rehabilitation, occupational therapy, etc.
When individuals with co-occurring alcohol use disorders and other mental health disorders focus on the treatment of their alcohol abuse and ignore these other conditions, their treatment will inevitably fail. Likewise, focusing on the treatment of the co-occurring condition and ignoring the individual’s alcohol abuse problem will inevitably lead to relapse. Thus, an individual in a comprehensive aftercare program will need all of these issues addressed at the same time.
- Participation in social support groups or peer support groups: Participating in social support groups such as Alcoholics Anonymous (AA) can help to significantly increase one’s chances of recovery. In addition, social support groups like AA can become the mainstay of a long-term aftercare program after an individual has completed their alcohol use disorder therapy since counseling and psychotherapy are often time-limited due to insurance regulations or other factors. Support groups like AA offer an individual a long-term resource to help them remain in an aftercare program that provides them with support, structured program of recovery, and the opportunity to stay active and focused on their recovery plan.
- Complementary and alternative treatments: These treatments, such as art therapy, music therapy, meditation, exercise programs, etc., have significant empirical validation to support their use as adjunctive treatments to therapy and social support group. Individuals who become involved in these different types of treatments can choose a form of intervention they like and continue involved in the intervention indefinitely. However, these programs are typically best suited for use when an individual is also actively participating in therapy or a social support group such as AA.
What to Look for in an Aftercare Program
The major organizations mentioned in this article, such as NIDA, APA, and ASAM, have also identified factors that are crucial to the success of an aftercare program. These principles include:
- The use of empirically validated treatment interventions: Empirically validated treatment interventions are treatment approaches that have sufficient research support to validate their use in addressing a specific situation, such as an alcohol use disorder. Being involved in most forms of psychotherapy and medical management for an alcohol use disorder satisfies this requirement.
Some complementary and alternative treatment programs also have sufficient research evidence to validate their use in the treatment of alcohol use disorder; however, social support group participation has some, but not an overwhelming amount, research evidence to support its use. This is because groups like AA often do not participate in formalized research studies due to their anonymous nature.
As part of this requirement, professional treatment providers should be licensed and certified in their areas of expertise.
- Use of a program that fits the needs of the individual: Even though research studies have identified generalized plans of interventions that should be followed in the treatment of an alcohol use disorder, not every person with an alcohol use disorder is the same. Aftercare interventions should be adjusted to suit the needs of the individual, including making accommodations for the individual’s medical history, cultural background, gender, age, social situation, education, and other variables, such as co-occurring mental health disorders or cognitive issues.
- Comprehensive treatment: The trend in aftercare treatment programs is to utilize treatment programs that address the individual at all levels, including their emotional needs, cognitive needs, social needs, etc. The days of simply attempting to address the individual’s alcohol abuse by helping them establish abstinence and getting them through the withdrawal period without considering other variables, such as the individual’s social situation, family, occupational situation, need for housing, etc., have gone by the wayside.
- Continuous evaluations: Successful aftercare programs continually evaluate the client’s progress, make adjustments to the program to ensure continued recovery, and then evaluate these adjustments. A successful aftercare program continues to assess and evaluate itself.
- Easy access: Aftercare programs are most successful when the individual can actually participate in them without experiencing a significant disruption in their other activities and/or responsibilities. This is one reason why social support groups, such as Alcoholics Anonymous, can be extremely useful in an aftercare program. Meetings often occur several times a day every day of the week in most urban areas.
- Accountability: One factor that is extremely important in a successful aftercare program is that the program stresses that the individual is accountable for their behavior. The individual is accountable for attending therapy sessions or social support group meetings, keeping medical appointments, taking their medication, and actively applying the principles learned in treatment to everyday life. This means maintaining abstinence in nearly all cases.
Thus, the aftercare program should have some objective measure to ensure the individual is maintaining abstinence, particularly in the first year of the program. Most often, this includes the use of urine analysis for drugs or alcohol, or breathalyzer tests for alcohol, by the individual’s therapist, physician, or some other trained and licensed individual.
- A sufficient duration of treatment: Research studies provided by or referenced by APA and ASAM consistently report that there is a strong relationship between success in recovery from an alcohol use disorder and the time spent in treatment-related activities. Groups like Alcoholics Anonymous maintain that participation in their program should continue for the individual’s lifetime. In general, some form of continued participation in an aftercare-related activity, such as social support groups, therapy, or complementary and alternative treatments, should continue for 5-7 years after the individual has become abstinent from alcohol before their probability of relapse drops substantially.
During this period of time, the individual should remain totally abstinent from alcohol and other potential drugs of abuse. Controlled substances and other medications should be used only under the supervision of a physician. Once an individual has retained abstinence and involvement in treatment-related activities for 5-7 years after they have discontinued alcohol, they are often considered to have been successful in their recovery; however, there are numerous cases of individuals relapsing after 10 or more years of abstinence. Thus, individuals need to remain vigilant and continue to apply the principles learned in recovery over the course of their lifetimes.