When is a client undergoing addiction services or psychiatric care ready to “get back to life?” That’s not only a question clinicians ask regarding a client’s potential discharge from a program, but also about their activities during care, whether regarding their release from rules that limit their access to their phone or computer or their ability to leave the grounds of a program or hospital unsupervised or pertaining to more liberating goals like living on their own, having a job or entering into a romantic relationship.
At Ellenhorn we have three beliefs about care that influence how we approach the idea of readiness. The first is based on significant research that has proven that all good therapeutic relationships are collaborative, meaning that people are more likely able to change if they feel they are leaders of their care and do best when they know that those treating them are on board with their life goals. The second, again based on research, is that a person’s sense of pride in themselves and belief in their own capacities is the main motivator in their willingness to change. The third is that people are rarely able to change if they don’t have, what social psychologists call, strong “social buffers,” i.e., a sense of one’s self-efficacy, positive social support, a feeling of purpose and the belief that one is valuable to the community. Without these social resources and proven factors in motivation, people are rarely able to move forward.
With these three beliefs as central elements in the Ellenhorn philosophy, we see “readiness” quite differently than other programs. For us, talking on your phone with friends, using your computer to research something, taking a walk on your own, living independently, being financially self-sufficient and falling in love are the most important medicines for change. And while we must always be thoughtful about the risk involved in each movement toward independence, restricting people from normal life activities is like saying that they can’t have any medicine until they are well. This leads us to the fourth element of our philosophy: the “dignity of risk.” In other words: We don’t believe that people are capable of change without possessing a sense of dignity and, since human dignity is closely tied to a person’s self-determination and control of their life, we believe that you can’t help people build their dignity if you are not willing to take risks in the process of helping them become more independent. For us, each step a person takes toward a life outside of treatment is not only a challenge of their readiness for it, but also, and often more importantly, a challenge to a program’s readiness.
At Ellenhorn we take our responsibility to be ready very seriously. Indeed, our entire “hospital without walls” orientation has been purposefully built to move with great agility and assertiveness in regard to a person’s steps toward growth. If a person feels ready to go back to work, we believe it is our job to make sure that their medication regimen matches this challenge, that we are able to meet them during lunch breaks to support them, that we plan to pick them up after their shift in order to debrief their day and that we use the therapeutic models we are trained in to help them better interact with their coworkers. If they feel ready to live on their own, we collaboratively work with them to schedule regular visits, we help them deal with their landlord, we formulate plans to help keep them organized and so on. If they’ve fallen in love, we’re there to support them with our therapeutic models, to help them debrief after a date and to offer relationship counseling—whatever it takes to support them in the medicinal elements of love. Each of these events is a risk, but each is also the very medicine we all need in order to face the heroic challenge of accomplishing personal change.
Here is one example of how our orientation regarding readiness positively influenced one person’s recovery and transition to a more meaningful life. We’ll call that client “Mary.”
Mary came to Ellenhorn seeking help with crippling anxiety and depression, and a problematic relationship with alcohol. She was a remarkable and well-respected graphic artist who worked on a contract basis with several advertising firms, however she often missed deadlines and/or dropped projects because of a chaotic personal life that was often marked by binging on alcohol and cloistering in her apartment for weeks at a time. At 27, Mary had a long history of both inpatient and outpatient treatment, and, like many of our clients, she struggled to maintain hope. She believed that her life was destined to remain exactly as it was: a never-ending mix of chaos and treatment. Mary’s referring psychiatrist diagnosed her as suffering from a personality disorder.
To build a treatment collaboration with someone is to find out where they want to be in the future. Mary’s goal was to gain more consistent work in her field than her current positions could provide. In fact, she hoped to gain regular nine-to-five employment within a company. She felt that the lack of structure missing in her current freelance work was detrimental to her psychological well-being. Mary had dropped out of a Master of Fine Arts program in her early 20s, but with one year of credits to her name could still attain that degree. She believed that an M.F.A. would help her secure more stable work. We helped Mary enter such a program, and spent time with her filling out the application, attending the orientation and adjusting her therapy sessions to fit her schedule. With Mary’s permission, we also contacted the school’s disability department to request that a notice be sent to her professors regarding her interpersonal skills and that reasonable accommodations, such as a longer time allotment for tests and the ability to attend class virtually upon request, be granted.
Mary excelled in the program, and we supported her throughout the process by making regular visits to her apartment after school, adjusting her medications to match her need to concentrate on schoolwork, employing Mentalization-Based Treatment to help with her interpersonal interactions with her classmates and professors, and using Motivation Interviewing to support her work on her addiction.
One month into her second semester, Mary approached her addiction therapist with some news: She had started drinking alcohol again and had been doing so for more than three months. While Mary had done a remarkable job of keeping up with her schoolwork during this period, she felt she could no longer go on this way, and wanted our help in stopping. We knew that the first move was for Mary to go into a detox program and we arranged for her to do so immediately. With her permission, we also called the disability department at her school, explained that she would be missing classes for a week or so and requested that all Mary’s coursework be collected from her professors so that she could complete it once she was ready. Once Mary was admitted to the detox unit, we met with her daily and often brought small portions of her coursework with us for her to complete. For us believers in the curative force of collaboration, pride and social buffers, this was the medicine Mary needed in order to recover. This, however, is not the norm on most detox units, which don’t often share our ethos regarding readiness and maintain the belief that a person’s sole job on the unit is to work on their sobriety.
Upon discharge from the detox unit, the counselors there recommended that Mary enter a residential substance-abuse program for 90 days. We, however, felt differently. Mary had been honest with us about her use, and, having witnessed our assertive orientation to maintain her pursuit of her dream, even while on the unit, we believed that she would be honest with us again. As the most robust wraparound service in the Unites States, we also believed that we could keep Mary safe and get her back to the medicine of school. We subsequently developed a plan for our vocation/education therapist to help Mary catch up on her schoolwork, for one of our licensed clinicians to drive Mary to and from school each day, to test her regularly for alcohol and drug use, to increase her meetings with her addiction counselor, to provide a substance-abuse coach from our team to take her to AA meetings and to keep everyone focused on helping Mary complete her dream as much as on her sobriety.
Mary received her M.F.A., and she invited us to her graduation. We celebrated after with her and her parents, and she soon found a job in the marketing department at a local IT company. Mary visited us the other day just to say “hi.” It’s been three years since her discharge from Ellenhorn and she’s been sober since she left the detox unit. She’s still at her job. She’s fallen in love.
Mary credits us with this change, but we know the true credit goes to her. She was ready to change all along; she just needed people around her who were willing to follow her growth.
