Monday, June 21, 2010

Stages of Recovery

The first stage of recovery is physical . The first phase of this is called "withdrawal'. This is the period of detoxification during which the actual drugs and alcohol and their metabolites are clearing from the system.

As the physician in charge of a detox unit, this was to us caregivers medically a potentially high risk period. People experience all manner of physical symptons including seizures and psychosis. It's associated with increased sweating, sometimes tremors, odd pains, unusual sensations, fatigue, oversleeping, insomnia and anxiety and depression. Not a particularly pleasant experience by any stretch of the imagination but usually over in days to at most a week or two.

There are many variables that affect the person physically during the withdrawal phase. First of all is age. The young do better than the old but the very young and the very old are at most risk. Healthy athletic people do better than people who are sick and decrepid. What and how much of the drugs and alcohol can affect the severity and prolong withdrawal. How long a person has been using can also affect withdrawal. Other medical condition such as heart disease, diabetes, HIV, pneumonia etc. can all complicate withdrawal.

Withdrawal is predominantly a physical process and people are often psychologically simply numb, in shock or insane. Much of withdrawal is quickly forgotten by many. Many people simply leave detox and despite the best wishes go out and begin drinking or using again. The successful go on to the second phase of recovery.

This second phase is the first season. Each week and month of recovery is a milestone at first but the 3 month stage is when the brain has most likely come back "on line" fully. The greatest relapse occurs in the first three months. Old timers in AA would say, "90 meetings in 90 days and if you don't like what you've got you can go back and restore your misery". Modern functional MRI's have shown now that it takes 90 days for the frontal lobes of the brain to begin to function normally again in recovery. The frontal lobes are what make us predominantly 'human' and account for our judgement.

Working now with mechanical brain injury after falls and motor vehicle accidents I am daily struck by how similar the recovery process is for addicts and alcoholics. It's caused me to call the latter condition 'reversible chemical brain damage". The 'mechanical brain injuries' though often do better because they lack the 'oppositional' , "non cooperative' and 'resistance to change' 'anti authority' issues that come along with addiction. This is commonly packaged under the term 'denial'.

The second, third and fourth seasons of recovery all appear to be associated with their own organic healing. Liver enzymes restore to normal for those with liver involvement. Given that the liver is the chief organ for metabolism of alcohol and drugs it's usually a safe bet that there has been some damage, reversible or irreversible to the liver. Commonly the heart and lungs are involved and these heal during this period. The thyroid can be involved and people will not uncommonly complain of a wide variety of physical symptons throughout this period.

Often there is also simple 'hypochondriasis' or somatic elements of anxiety and depression. Nonetheless it needs to be observed carefully as commonly alcoholics and addicts have not given much care to the maintenance of their bodies. Exercise, good food and good medical care are very important in the first year. Most commonly too there is a need for a dental visit.

Many of the drugs of abuse affect a person's ability to perceive pain properly with the consequence that dental caries go unnoticed, joints and muscles are strained and injuries and illness ignored cometo the fore. The person literally wakes up to life in their body without the constant distraction of drugs and alcohol. Gastritis, pancreatic, and various intestinal complications of ingesting toxic waste are also common.

The whole first year is as much physical as it is psychological. St. Francis described his body as 'Brother Ass" or "Brother Donkey". Our body's are the first baby we're given the care for and addicts and alcoholics are notoriously immature parents when it comes to taking over the responsibility of their bodily care from their parents, institutions, asylums, schools or other care givers. In the first year they have to restore homeostasis to a wide variety of physical systems that have been quite frankly traumatized. Sleep cycles, energy cycles, appetite, bowel patterns and much more all have to be routinized and ordered. The longer the addiction has been prevalent in a person's life the more disorder and chaos is present in their physical self.

Psychologically the first year is associated with extreme anxiety, panic attacks, mood swings, irritability, depression and sometimes hypomanic episodes.

The underlying disorder of addiction is an anxiety disorder. Mostly the anxiety is a 'social phobia'. Alcoholics and addicts in the first year of recovery commonly present as bipolar disorder and many actually have post traumatic stress disorder.

Psychiatric psychotherapy has to be used wisely and judiciously during this first year because many psychotherapies and counseling techniques that have 'curative' value for people without addiction are 'anxiety provoking'. All the analytic and 'insight' therapies fall into this category.

Talking about past abuse in the first six months with patients in recovery can easily increase their anxiety when they still only know how to cope with anxiety by abusing drugs or drinking. Many a well intentioned therapist without training in addiction has done alcoholics and addicts tremendous disservice through their ignorance and grandiosity.

Motivation therapy, Cognitive Therapy, 12 Step Facilitation therapy, and Supportive therapies are all mainstays of the first year of recovery. The cornerstone of psychotherapy in the first year is the group therapy. AA, NA, SMART, CELEBRATE are just some of the acronymns for group therapies which have proven critical to the recovery process because of the centrality of interpersonal disturbances and deficits.

Any drug with a street value is by rule of thumb contraindicated in the psychopharmacological care of those in recovery in their first year. Most addiction specialists would question any drug with addictive potential and think very carefully about it's use in the first 3 to 5 years of the recovery process if not more.

The World Health Organization originally used one year as the bench mark for the first stage of recovery. The Diagnostic and Statistical Manual of the American Psychiatric Association also uses 1 year as the period of time needed for this process of basic physical and psychological recovery. It is a year before a person with addiction is said by the DSMIV to be in full sustained remission.

Stage II recovery has referred to the psychosocial recovery period that while beginning in the first year really takes off in the second year. During this period patients in individual and group therapies are decreasingly psychotic and more likely able to engage in controlling knee jerk emotional reactions, addictive tendencies to blame others, rage attacks, and well honed projective, dissociative and acting out defences.

It's been said that in this second year of recovery psychologically a person can actually enter into an hour of interpersonal interaction and come away with a fair likelihood of saying truthfully who said what and what emotions were involved in the process. In this phase of recovery the self absorption and egomania (defensive or offensive) is less overwhelming. Addicts and alcoholics in recovery can actually have conversations and discussions and tolerate the thwarting of their wishes, accept negative feedback and actually consider compromise and diplomatic resolution of conflicts. Suicide and homicidal thinking are not all that is going on between their ears as they behave and smile pleasantly but still don't get their way

In the third year it's been said that a person in recover begins to be able to actually report clearly the communication that occurred when three or more people were present in a room. This is the recovery at the community level. So much of addiction is self absorption and isolation that the road of recovery is often described as a journey back into normal society. During this phase of recovery people who have often taken more than given throughout their addiction and caused significant damage are able to really contribute at the community level. Recovery now involves participation not only in the recovery groups themselves but as volunteers in political organizations, churches, and community centres and functions. Recovery is at this stage is recognized as a time of reintegration into mainstream society.

Addicts and alcoholics have commonly made a virtue of necessity and chosen paths and associations which have allowed for their addiction to thrive. In recovery a person will order their lives with increasing organization, social involvement and commitment.

It's recognized that the addict in the past had to be 'available' for the 'call of their master' so increasingly avoided any activity that might come between them and their addiction. In the third year of recovery addicts commonly return to school, take night school course, taking part in committees, join boards and become apart of organizing events. It's not what 'feels' good to the addict but what 'is' good that motivates the person in recovery. Despite the difficulty that follows long years of addiction persons in recovery look to the example of others in society who have avoided addiction and follow in their paths.

When professionals have returned to work urine testing normally goes on till at least three years because of the high rates of relapse that persist this long after sobriety is established. The addict or alcoholic commonly thinks they're 'cured' much earlyier (some hours after their last drink or drug of abuse, in fact) but it's not till three years later that saner minds feel the prognosis is potentially good.

Addiction and alcoholism are deadly diseases. Asylums and jails are full of alcoholics and addicts. Anyone who works with alcoholics and addicts has heard all the promises but seen the relapses over and over again despite the best intentions. Even with the best of care and resources patients can relapse though the chance of this decreases most significantly with time.

It is only at five years that Dr. Vaillant, head of Harvard Psychiatry and a leading addiction specialist actually showed that the risk for the recovered addict or alcoholic relapsing to their previous level of abuse and chaos compared with the potential risk of a 'new' unknown case of alcoholism or addiction arising in a socalled normal population.

Some have called addiction 'cancer of the mind' and like physical cancer, it's only at five years that medically recovery is seen to be 'well established'. Professionals, pilots and others having urine testing as part of their return to work policy can encounter employers who want urine testing and psychiatric and medical supervision to persist at least till 5 years.

This concern isn't punative. It's simply a product of the disease. This 'reversible' mental illness can have severe societal consequences without the addict or alcoholic being able to recognize their risk to themselves or others.

Recovery could be said thereafter to be a lifelong process. There is no clear consensus in research on 'stages' or phases beyond this even though in AA it's thought that 10 years is required before a person is over the most devastating spiritual consequences of the disease of addiction and alcoholism. The long term physical and psychological and social consequences of the disease of addiction may go on forever.

One man killed another in a black out. There's no taking that back. He knows it's true because he saw the video and spent 10 years in jail. He now goes to jail AA meetings. There he tells his story, doing this community service with alcoholics and addicts who have themselves committed crimes while under the influence. Recovery is the road back to health, saniety and society.

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