8 ways leverage works to improve outcomes
Today’s topic could be called “Why We Love Leverage.” That’s because we use it for many purposes, including compliance with treatment recommendations, signing releases, and drug testing. As mentioned in past blogs, programs for substance-dependent physicians use leverage for similar purposes and achieve spectacular results when compared to other approaches.
To refresh: A high percentage of people who need treatment do not believe they need it and do not perceive themselves as having a problem with alcohol or drug use. Therefore, they are resistant to being forced into treatment. Adopting a leverage-based approach allows the family, working with their professional, to adopt a long-term strategy to address the addiction, including chipping away at the self-perception problem over many weeks, if not months. Continued pressure provides situations for the addict to develop insight into the disease over the stages of recovery.
Currently, no treatment center offers the medical board model to non-physicians, so we adapt and modify their model. Here’s why leverage is needed and how it works.
1. To help the addict complete the stages of recovery.
A recent article in a professional addiction journal discussed the developmental approach to recovery and the six stages to achieving stable remission:
- Transition – Recognition of Addiction
- Stabilization – Recuperation
- Early Recovery – Changing Addictive Thoughts, Feelings and Behaviors
- Middle Recovery – Lifestyle Balance
- Late Recovery – Family of Origin Issues
- Maintenance – Growth and Development
In our experience, this is a two-to-five-year process, depending on the progression of the disease, severity of use, and co-occurring conditions (trauma, abuse, learning, mental health, etc.).
Leverage becomes especially important in the second stage.
Stage Two: Stabilization – Five Tasks to Facilitate:
- Achieving recovery from withdrawal.
- Interrupting active preoccupation.
- Creating short-term social stabilization.
- Learning non-chemical stress management.
- Developing hope and motivation.
These stages take much longer than 28 days, which is why leverage needs to be maintained over many months – and also why relapse is so common: Addicts leave treatment without being stabilized. (By the way, did your loved one’s counselor ever tell you where s/he was in the recovery process? I think not!)
2. To allow time for converting external motivation to internal motivation to recover.
Therapeutic leverage to enter treatment and comply with post-treatment recommendations is needed because it is very difficult for people with substance dependence disorders to change harmful behaviors on their own.
The goal is to maintain pressure until the person develops sufficient internal motivation to want to remain abstinent and active in a program of recovery on his/her own volition.
Internal motivation to recover is a much stronger indicator for success than external pressure. However, because the degree of internal motivation is measured by acts and attitude, rather than talk and intentions, it takes time for internal motivation to “kick in” and show itself – again, usually more than 28 days, especially after relapses.
To be effective, leverage must be used with sophistication and discretion and is much more a carrot-and-stick proposition than raw force. For the affluent, leverage comes from controlling money, participation in family businesses, access to family resources, and relationships. Leverage is most effective if senior family members, trustees, or others in positions of power support its use and are united when dealing with an addicted family member.
3. To obtain full releases of information.
One key element in recovery is open communication among the substance user, treatment center, and key players in the addict’s life. Substance dependence lives in secrecy, with the person often leading a double life and understating the amount and number of drugs, when caught. Insisting on being informed on treatment of your loved one’s disease is not only good practice but sends the message that your relationship is now different.
Leverage is an effective tool for encouraging an addict to sign releases. It is indeed more than ironic that so often families pay for treatment and then a wall of silence is erected based on confidentiality laws.
Affluent patients often will sign only partial releases and withhold information about post-treatment recommendations if the recommendations defy the patient’s wishes. One way to counteract game-playing by addicts regarding the scope of the release is to request the treatment provider to send a copy of the signed release to the professional hired by the family, who will understand any limitations in the document.
4. To encourage signing recovery contracts.
These contracts specify activities the addict will engage in when leaving treatment, such as counseling, drug testing, meeting attendance, etc. It usually includes a relapse plan and an agreement to sign releases of information for all therapists, who must be approved as addiction specialists. In exchange, the contract specifies expectations regarding support by the family or trustee for recovery activities and lifestyle.
If the person leaving treatment does not agree to the contract, the family can refuse to support him/her or provide minimal support, depending on their level of comfort.
5. To encourage long-term compliance with all treatment recommendations.
Failure to comply with treatment recommendations is the No. 1 cause of relapse. If a person had cancer and all they had to do to recover was follow treatment protocols, they would do so without fail.
Substance-dependent people – who also have a chronic disease where there outcome is death or disability – commonly ignore advice from professionals and go back to their old ways. Leverage encourages long-term compliance.
6. To require effective and comprehensive drug testing.
This should not even be up for discussion, given anyone’s history with an addict. Not only is it very wise to condition support and access to family resources on regular, observed, full-screen tests (because addicts lie), but testing helps keep loved ones on the path to recovery because they know they will be caught if they use.
7. To allow early intervention in the event of relapse.
When combined with drug testing and a written agreement as to what to do in the event of relapse, leverage provides for fast intervention before a relapse gets out of hand.
One problem with people who relapse is they can do so for some time before others become aware of it. Then, they deny it happened, and if proof exists, claim it was a one-time occasion. This is why drug testing is so important: It is undisputable data regarding use. And it allows for quick interceding before relapse becomes embedded.
8. To increase consequences of use to make the disease real.
One major block to recovery for affluent, substance-dependent people is that they suffer few external consequences from their use of drugs and alcohol. Research shows that the more consequences a person experiences, the more likely they are to take their disease seriously and take action to abstain and recover. For the affluent, a key challenge is figuring our how to recover without losing everything.
Making the disease more real
By using leverage to accomplish the goals in topics one through eight, we are in effect Creating Consequences™ by making the disease more real: Drug testing, recovery contracts, and treatment compliance create accountability and require action upon leaving treatment. Along with the written plan in the event of relapse, it means that if the addict returns home and takes it easy – does nothing much regarding further efforts at recovery – there will be consequences. The hard work begins after leaving treatment, and leverage provides the foundation to encourage continued progress towards stable recovery.
 Recovery From Addiction, A Developmental Model, Part One, It’s All in the Journey, Sept. 2008, p. 8.
 Ibid, p. 12.
 Satel, Sally, M.D. 2006. “For Addicts, Firm Hand Can Be the Best Medicine.” The New York Times, Aug.15.
A myth is that the addict must be motivated to quit – that, as it is often put, “You have to do it yourself.” Not so. Volumes of data attest to the power of coercion in shaping behavior. With a threat hanging over their heads, patients often test clean.
Goodman and Levy. Biopsychosocial Model Revisited. p. 3.
Chemically dependent patients, free of co-existing mental illness, with intact jobs and family, tended to do well in rehabilitation programs if families and employers applied therapeutic leverage and support.
Susan Merle Gordon. Relapse & Recovery: Behavioral Strategies for Change. Caron Found. Rept. 2003: p. 18.
Internal motivation is a more powerful predictor of recovery than external motivation. Moving from external motivation to internal motivation is a long process. Therefore it is critical for external pressure to continue until this transition is fully underway, if not complete. The failure to follow this advice is a major cause of relapse (paraphrased from report).
Chuck Rice. “Impaired Lawyers Overcome Denial, Stigma to Achieve Road to Recovery.” Hazelden Voice. Vol. 9, No. 2. Summer, 2004.
My experience with attorneys tells me that long-term outcomes are dramatically improved when lawyers can be monitored and when there is an accountability system with a fair amount of external support.
Alan I. Leshner, Former Director, National Institute on Drug Abuse. National Institute for Mental Health. Science and Technology. Spring, 2001: p. 2.
Treatment compliance is the biggest cause of relapses for all chronic illnesses, including asthma, diabetes, hypertension, and addiction.