Take a deeper look at some of our programs. Below are oveviews covering some of our treatment approaches from the beginning of detox to the journey of a life in recovery.
Trauma Integrated Addiction Model
At CeDAR, we have been expanding our treatment approaches to better serve those seeking recovery that have more complex needs. About two-thirds of the patients who seek help at CeDAR have survived one or more significant traumatic events. This estimate is based on several research studies as well as national statistics on traumatic events and Posttraumatic Stress Disorder (PTSD). The sources and types of their traumatic events vary from large T (shock trauma) events such as automobile accidents, sexual assault, and life threatening illness, to small t (developmental trauma) events such as childhood emotional, sexual or physical abuse and neglect.
The significance of the co-occurrence of addiction and trauma cannot be overstated! First, years of clinical research tell us that individuals who have a diagnosis of PTSD are four to five times more likely to also have a substance use disorder. Second, individuals who struggle with both addiction and trauma often begin using chemicals earlier, have more advanced progression of their disease, and have poorer treatment outcomes than individuals without any trauma history. Most importantly at CeDAR, we recognize that active trauma symptoms expressed throughout the addiction treatment process interferes with our patient’s ability to hear and implement the recovery message. Failure to address these trauma symptoms during treatment sets up relapse for many patients.
Since the early 1990s, many treatment providers have been addressing these co-occurring issues by developing “trauma informed” clinical programming. Trauma informed treatment recognizes that the experience of traumatic events can negatively impact individuals’ sense of self, while also altering their assumptions about the safety of their surroundings and the people in them. These altered perceptions can interfere with patients’ ability to develop therapeutic relationships and to fully engage in a treatment process that challenges them to look closely at important and painful events associated with their drug and alcohol use and any traumas that resulted. Trauma informed care is not intended to treat past traumatic events, but is focused on providing a safe treatment environment where staff members understand and are respectful of the impact of trauma on the treatment needs of all patients and where organizational and treatment policies and procedures limit the re-traumatization of trauma survivors throughout the addiction treatment process.
Based on recent advancements in how much we know about the brain and how traumatic memories are processed, we recognize that there is far more that can be done in addiction treatment, with current trauma symptoms than was previously thought. Based on these insights, we have evolved our “trauma integrated” model of addiction treatment. Our model, built on the foundation of trauma informed principles, works to address those current, day-to-day trauma symptoms that prevent patients from fully integrating in treatment, from trusting treatment professionals and peers, and from using the recovery messages needed for both short and long term treatment success. CeDAR has embraced this philosophy and has assumed a leadership role in the development of a trauma integrated addiction treatment model.
Trauma Integrated Treatment and Understanding Memory Systems
To truly integrate treatment for current trauma symptoms into existing addiction treatment, we incorporated new insights into how trauma memories are stored and how they are experienced by individuals. While many patients report remembering a traumatic event in great detail, our team of counselors recognize that there are multiple “memory systems” that hold and maintain different aspects of trauma memories and that a patient’s story may not be as accurate as they believe. It is for this reason that we believe it is most appropriate to focus on current trauma symptoms that arise throughout the course of the addiction treatment process.
While it is difficult to summarize the sophistication of our brain’s memory systems, it is important to know that the brain responds to memories that are experienced as highly stressful or traumatic by shutting down language centers and stimulating the centers that record sensory experience. The result is that “event memories” of traumatic events are most often experienced as perceptual or sensory in nature. In turn, a patient’s trauma story is often incomplete or unavailable. Event memories are timeless and are experienced as if the individual is re-experiencing the traumatic event.
“Procedural memories” are the automatic and unconscious cognitive, emotional, and behavioral responses that are started when event memories are triggered. These procedural responses are what seem to interfere most with participation in addiction treatment programs. While these proceduralized behaviors work to shift an individual’s awareness from the traumatic event, they are experienced as urgent, here-and-now disturbances or crises that need immediate attention. These procedural responses can derail the trauma survivor’s ability to focus on their addiction treatment and they are often disruptive to the treatment of other patients in the treatment program.
Since addiction treatment requires learning, understanding and integrating new recovery oriented information, it is important for patients to remain as present, mindful and non-anxious as possible throughout treatment and 12 Step support activities. For individuals with a trauma history, homework assignments and other treatment activities can trigger event and procedural responses that can significantly impact their ability to focus on recovery. Research has shown that individuals who are actively engaged in remembering traumatic events become increasingly anxious, which prevents access to the parts of the brain that integrate learned materials in the decision making process. In order for patients to be able to access critical thought processes required for ongoing recovery, we must teach them tools for reducing anxiety and dealing effectively with the event memories and procedural response patterns.
Assisting patients to stay engaged and able to fully benefit from addiction treatment requires a counselor to understand and recognize what memory system the patient is working in. Different memory systems allow for the use of different treatment modalities. When a patient is calm and fully engaged in the treatment process, insight oriented therapies such as Cognitive Behavioral Therapy or Motivational Interviewing can be used to assist the patient to learn new information and work on the achievement of recovery milestones. If a patient is operating out of the event or procedural memory system, with significant anxiety, anger, and emotional dysregulation, behavioral interventions and emotional regulation techniques should be initiated until the individual is again able to engage calmly in treatment.
The CeDAR Trauma Integrated Model of Care
Trauma Assessment is a key component of the CeDAR trauma integrated model. We utilize two specific assessment tools, the Structured Clinical interview of the DSM-IV (SCID) and the Trauma Symptom Inventory-2 (TSI-s), to assist in identifying those patients who are in need of specific treatment of current trauma symptoms. These tools are significant in that they give the clinical team a solid overview of a patient’s trauma symptoms, while also assisting the team in developing a treatment plan that is trauma informed and targeting trauma symptoms that prevent full engagement in addiction treatment.
Training is another key component of the CeDAR trauma integrated model of care. All staff members have received trauma training to assist them in identifying and understanding the signs and symptoms of the disorder, how patients with a trauma history can be triggered in the course of addiction treatment, and how to address day-to-day trauma symptoms. The clinical team has received specialized treatment in Containment and Autonomic Regulation (CAR) Therapy and Dialectical Behavior Therapy. Both models have been found to work with trauma within an addiction treatment environment and both are very effective in assisting patients to resolve problems associated with negative emotional reactivity.
The goal of the CeDAR integrated model of care is to allow patients to deal with the anxiety, dissociation, and anger that is commonly associated with trauma memories, while also benefiting from the therapy groups, individual counseling sessions and 12 Step support activities. In this process, counselors are challenged to match therapy interventions, assignments, and therapy content to the memory systems being exhibited by their patient at any given time. If a client is able to stay calm and non-anxious, the goal is to proceed with educational objectives and insight oriented “talk” therapies. When the patient is experiencing active trauma symptoms, the treatment objective is to assist the patient by utilizing CAR based resourcing activities or dialectical behavior therapy skills. Patients are challenged to practice these skills several times per day, with a goal of establishing new coping options when future event memories are triggered. Patients also participate in coping skills groups weekly. These groups are based on dialectical behavior therapy interventions and teach patients to effectively manager strong emotions and learn to tolerate pain and other distressing emotions. We are also in the process of developing resourcing groups that are based on the first two phases of the CAR Model. Clients are challenged to practice resourcing skills and appropriate relational abilities while roleplaying current life and recovery stressors.
For years, individuals who have suffered with addiction and trauma have struggled to achieve and maintain lasting recovery. The CeDAR Trauma Integrated Model has been developed to give these individuals a fighting chance to not only get sober, but to begin healing the significant traumas in their lives. We built the model on a foundation of trauma informed principles, sound assessment tools, and state of the art trauma and addiction treatment methods. Our staff has been trained to understand how trauma memories are process, to recognize memory systems and to target treatment interventions to assist patients to deal with their emerging trauma symptoms. Ultimately, our goal is to assist patients to effectively resolve the day-to-day trauma symptoms that hijack them from working on their primary addiction and to maintain a state of mind that allows them to utilize the recovery messages learned in treatment activities.
Author: Michael Barnes, PhD, LPC, CeDAR Clinical Program Manager
Gender Responsive Treatment
The Center for Dependency, Addiction and Rehabilitation (CeDAR) at the University of Colorado Hospital offers gender responsive, trauma informed treatment for men with substance use and psychiatric disorders. Gender responsive can be defined as: creating a treatment environment through site selection, staff selection, program development, and program content and materials, that reflects an understanding of the realities of men’s lives and that addresses and responds to their challenges and strengths” (Covington, S., Griffin, D., Dauer, R., 2011).
There is accumulating evidence suggesting that gender is an important variable in addiction treatment and prevention. Studies have shown that gender differences are present in all phases of drug abuse to include initiation, escalation of use, progression to addiction, withdrawal, relapse and treatment (Carroll, M., Lynch, W., Roth, M., Morgan, A, Cogrove, K., 2004). These differences present various challenges and barriers for men. Therapeutic approaches at CeDAR address these specific challenges in order to ensure optimum therapeutic benefit and encourage sustained recovery.
From the emerging literature, men tend to begin substance use at a much earlier age than women (NSDUH Report, 2004). Due to earlier onset of use, the progression of the disease of addiction will yield different consequences for men who become dependent more quickly. Men are more affected in education, work history and life goals. There is also a difference in gender experiences with the criminal justice system. Conduct problems and social deviance are more prevalent in the male gender. The rate of relapse differs and CeDAR’s clinical experience shows there are more chronic relapsing men entering treatment than women. In order to address these male specific consequences, therapeutic approaches utilized at CeDAR will focus on gender-specific cognitive, emotional and behavioral interventions, moral reasoning skills, and transition into employment and life goals.
The social-psychological development of males creates specific “man rules” that men follow consciously and unconsciously. These “rules” allow men to navigate through life and guide the way in which they interact in their relationships. Men learn “what acceptable behavior” is in order to “be a man.” For example, men are raised to ignore emotions and not express them unless it is through anger and/or aggression. Men are constantly reminded to not “be weak.” The therapeutic community is extremely important in addressing and changing these false belief systems. CeDAR provides an environment in which men can feel safe and begin to engage in the discussion of how these unspoken “man rules” have affected them and continue to affect them to date.
With the help of CeDAR clinical staff and the Family Program, interventions are used to begin building stronger bonds and help integrate the male patient into the family system. Women with addiction are more likely to be intricately involved with their children and their family and men are more likely to “abandon” their family and/or be more emotionally detached. Therapy focuses on dealing with guilt, shame and core beliefs about the male role in the family system.
CeDAR’s treatment model is congruent with practice skills, attitudes and policies that successfully work together ensuring gender responsive optimum care. CeDAR recognizes recovery is more likely to occur with culturally competent knowledge and skills compatible with the backgrounds, families and communities of the population it serves.
Through male-specific curriculum and education, CeDAR utilizes therapeutic approaches sensitive to the social construction of gender, impact of abuse, trauma, and sexuality which will ultimately strengthen the recovery process and deepen internal changes. There is a clinical focus on the social roles and cultural expectations placed on males. These expectations result in gender-specific stigma and stereotyping that may be detrimental to lasting recovery if not addressed. Treatment at CeDAR, aims at assisting the male gender with lowering defenses, becoming amenable to the therapeutic process, and improving treatment outcomes.
Becker, JB., Hu, M., (2008). Sex Differences in Drug Abuse. Frontiers in Neuroendocrinology, Vol29 (1), p 36-47.
Carroll, M., Lynch, W., Roth, M., Morgan, A, Cogrove, K., (2004). Sex and Estrogen Influence Drug Abuse. Trends Pharmacol. Sci. 25. p 273-279.
Covington, S., Griffin, D., Dauer, R., (2011). Helping Men Recover: A program for treating addiction. San Francisco, CA: Jossey-Bass
National Survey on Drug Use and Health, Data Collection Final Report, 2004
Authors: Osvaldo “Ozzie” Cabral, MA, CAC III, CeDAR Team Leader, Men's Treatment Services
Anne M. Meese, LCSW, CACIII, CeDAR Team Leader, Women’s Treatment Services
Aftercare Planning and Extended Care I used to pass by a bar called The Recovery Room on my way to work. Quite a twist on words, I always thought. If you take the meaning of recovery as the return to a previous state of mind or well-being after some kind of setback, then that bar was very appropriately, and cleverly, named. Taken to mean the on-going process of personal growth, discovery, and change, the word recovery means something else, indeed. All dimensions of a life well lived despite addiction, compulsion, heartbreak, trauma and loss, can have meaning and fulfillment when recovery is accepted as an on-going process.
This is what we at CeDAR understand recovery from addiction and dependence to be, and it is one of the driving motivations behind our treatment team commitment to develop a continuing care plan with each patient and family we work with. The reality is that the longer a person remains in treatment, the greater the likelihood he / she will be able to achieve long-term recovery so that collaboration with patient, family and referent is key to moving forward on the path begun during the person’s initial phase of treatment. A comprehensive plan for recovery is necessary to make that goal a successful reality.
Once a person makes the shift from “being in treatment” to believing they’re “in recovery,” the first steps towards a blueprint for life have already been taken. When people begin to recognize the destructive consequences of their addiction and / or co-occurring disorder as a cycle, the shift can occur; when they get the first awareness that what got them into treatment was not a sudden, one-time thing that happened because of outside forces in their lives nor was it just one more event in a string of bad luck “that always happens to me.” They begin to see the patterns of thinking and behaviors that have led to this moment in time, and with the continuing care plan, they begin to see a way out.
A critical concept in recovery is understanding that although a person may be powerless over drugs, alcohol, compulsive behaviors, and other people, they actually do hold great personal power over the changes they wish to make in their lives. This can mark the “second chance” a person and his/her family have been seeking. It is also considered critical that at this milestone, families and supportive others in the recovering person’s life remain as active participants in continuing care. This is not the time to say, “OK, we’ve given you treatment (maybe more than once) and now it’s time you assume responsibility for your life; finally you can act like you’re supposed to.”
This juncture in the patient’s recovery path – though often frightening, maddening, and painful for all concerned – is important for two very different reasons: 1) it holds the promise of change for the better that perhaps hasn’t existed for a long time, and 2) it can mean a quick return to old ways of thinking and behaving because of unrealistic expectations. For family and loved ones to determine the kind of support they will give to their recovering relative because of beliefs they have about treating addiction and mental illness can prove to be folly. If they have not been educated about the nature and theory of recovery from addiction, if they are basing their beliefs on the treatment experience of a few people they know or have heard about, if they allow their own intense emotions about the situation to drive their decisions, then this critical moment can mark a return to the pattern of trying in vain to control the unpredictable and unmanageable consequences of addiction in another person instead of marking it as the crossroad where they, too, accepted their own cycle of progressive pain and loss as being too much and admitting that they also need help.
It is at this point that the importance of having a plan that addresses the continuing care needs of the individual and family becomes clearer. When family and loved ones accept that they also need help drawing new boundaries and establishing self-care practices, the decisions that need to be made about this next phase of treatment are easier to reach. Loved ones become intuitively aware of the difference between the type of support that enables the individual’s addiction vs. support that promotes their recovery. People begin to see that they need help deciphering the signs and warnings about old behaviors that may occur along this new path and that they will continue to need help as recovery progresses.
This is the foundation of our approach to continuing care planning and recovery management at CeDAR – that people need help seeing past the barriers to forward motion in recovery, and it is our commitment to be there to support people through that process, regardless of where we meet along their individual path.
For families and loved ones, this will include an invitation to participate in the CeDAR Family Program, the identification of self-help resources for on-going support close to home, to become familiar with other treatment programs specifically designed to address issues of codependency and the family disease, and to receive recommendations for therapy that will meet their individualized needs.
For the patient, this will mean development of a plan that addresses issues related to on-going medication management, relapse prevention, co-occurring disorders that may exist, process addictions, family communication and healing, trauma, grief and loss, resolution of legal matters, reintegration into the home and back to work, and fitness and leisure activities that support recovery. As well, a major component of treatment and every continuing care plan developed at CeDAR is clarification of spiritual and inner life beliefs vs. religious issues. The spiritual element of recovery is considered to be vital because in the end it holds the inspiration for a lasting and meaningful recovery. Believing the definition of recovery to be merely a returning to where you were after a setback could never provide people with the feeling of being connected to others and to neither nature, nor the deep knowing that they fit into and are safe in the world, nor the sense that there is hope in recovery. Those milestones in a life well lived are the gifts of on-going recovery work. Over time. One day at a time. And a wonder to behold.
Author: Anne M. Meese, LCSW, CACIII, CeDAR Team Leader, Women’s Treatment Services
Prolonged and repeated substance and alcohol use often leads to physical dependence, which means that if the substance is no longer used an acute withdrawal condition will occur. The symptoms of withdrawal vary depending on the type of drug that has been abused. Alcohol and benzodiazepines such as Xanax, Valium and Klonopin can produce withdrawal symptoms such as tremors, nausea and vomiting, agitation, anxiety and more serious problems such as seizures and delirium that can lead to death if not properly assessed and treated. Withdrawal from opioids such as Oxycodone, Morphine, Heroin, Hydrocodone and Methadone can cause a flu-like illness, nausea, vomiting, muscle aching, runny nose and eyes, yawning and gooseflesh. While such symptoms are miserable unlike the sedative medication, opioid withdrawal is not associated with life-threatening complications. Generally, withdrawal from marijuana and stimulants does occur but not life-threatening. Regardless, of the drug or substance, often detoxification, is terrifying for most patients and can be quite uncomfortable.
Since detoxification is a prelude to the rehabilitation process, CeDAR providers understand the importance of a safe, comfortable and medically sound experience to encourage further engagement in treatment. At CeDAR, our practitioners recognize the complexities of not only drug and alcohol withdrawal management, but are also skilled at addressing and treating the many medical, psychiatric and nutritional complications that are common in patients entering treatment for substance abuse. CeDAR’s location on the University of Colorado Hospital campus assures that all levels of detoxification can be provided rapidly if the need arises. Our goal is to provide comprehensive detoxification services that include a thorough assessment of the patient’s medical condition, psychiatric co-morbidity and substance use history and deliver efficient and complete medical treatment based on the needs of the patient.
Author: Patricia "Patti" Pade, MD, CeDAR Addiction-Certified Primary Care Physician
One form of illness we treat at CeDAR is called a personality disorder. This is an example of a ‘psychological illness’ in that it involves defense mechanisms, patterns of relating with others, and dysfunction from developmental years to adulthood. A personality disorder can be very pervasive and affect many areas of a person’s life, including career, friendships, and marriages. Examples of personality disorders include Borderline Personality, Narcissistic Personality, and Antisocial Personality. These illnesses often involve relational drama, strong swings in emotions, and an unstable sense of self. Many times, childhood abuse can lead to these psychological patterns. If you or a family member has received many different diagnoses from psychiatrists over the years and it is tough to know what to believe, often times a personality disorder is at the heart of the problem.
While depression, bipolar disorder, and schizophrenia are often treated with medications, a personality disorder is treated best with the use of psychotherapy. At CeDAR, we provide some specific therapy tracks that help patients with personality disorders lead better lives. One example of this therapy is called Dialectical Behavioral Therapy (DBT) and is very helpful for a person with Borderline Personality Disorder. DBT helps patients build coping skills and tolerate the ‘gray zones’ in life (rather than always living a life of love versus hate). We also stress helping patients and their families hold firm boundaries in relationships. This is imperative for helping anyone with a personality disorder.
By helping patients with personality disorders get the care they need, they stand a better chance of maintaining their recovery, staying clean and sober, and living a life in peace. Please ask us about the care we provide, and we’ll be happy to explain more.
Authors: Patrick Fehling, MD, CeDAR Attending Psychiatrist
The relationship between substance use disorders and other psychiatric disorders is complex and bidirectional, i.e. most psychiatric disorders increase the likelihood of a substance use disorder and many psychiatric symptoms can be caused by the use of addictive substances.
Bipolar disorder has a 50 % comorbidity with addictive disorders, i.e. 50% of persons with bipolar disorder have substance use disorder, (40% of bipolar II patients and 60% of bipolar I patients.) Proper treatment of a co-ocurring psychiatric disorder significantly improves the rate of recovery from a substance use disorder.
However, most psychiatric symptoms in persons with active substance use are caused by the substance use itself. Depression, anxiety, insomnia and attentional problems are the most common symptoms caused by addictive substances. Other forms of cognitive impairment and manic and psychotic states can also be seen. Addictive substances can also temporarily improve some of these symptoms but in the long run will make them worse, leading to a vicious cycle of self-medication with diminishing results and worsening symptoms.
The presence of significant psychiatric symptomatology preceding the onset of substance use or during periods of sustained abstinence as well as family history are important clues to a co-ocurring psychiatric disorder. Rapid improvement of symptoms with detoxification is an important clue that the symptoms are substance induced. However, substance-induced psychiatric symptoms (referred to as post-acute withdrawal) often persist beyond the detoxification period well into the first year of sobriety.
Causation in many cases is not clear. Fortunately, it is not usually necessary to be fully certain of causation before starting treatment. We have many safe, effective, non-addictive psychiatric medications that can help whether the distress is caused by a co-ocurring disorder or the substance use itself. Thirty years ago it was common practice not to treat comorbid depression until patients had achieved 4-6 weeks of sobriety. Since then, evidence has developed that treatment of comorbid depression in newly detoxified patients improves outcome whether the depression is substance induced or not. Additionally, our multidisciplinary staff are trained and skilled in a variety of non-pharmacologic approaches, including cognitive-behavioral therapies, acupuncture, and dialectical behavior therapy, which also help patients dealing with emotional distress.
In general, we avoid the use of addictive medications in the psychiatric treatment of our patients at CeDAR. Rare exceptions are made where there is strong evidence for a co-occurring disorder and non-addictive pharmacologic and non-pharmacologic alternatives have been exhausted.
Of course, we do use some addictive medications for the primary treatment of withdrawal syndromes—benzodiazepines or phenobarbital for alcohol withdrawal, phenobarbital for sedative-hypnotic withdrawal, and buprenorphine for opiate withdrawal. And in some cases we use buprenorphine for ongoing treatment of opiate dependence beyond the detoxification phase (see section on medication-assisted treatment for opiate dependence.)
Development and maintenance of sobriety and addiction psychiatry follow-up are essential for the optimal outcome of all psychiatric comorbidity. We discharge all patients with a detailed recovery aftercare plan specific to the individual case. For patients discharged on psychiatric medications we refer patients whenever possible to trained and certified addiction psychiatrist. The growth of telepsychiatry is making this more feasible and convenient in many remote underserved areas. How long to stay on medication is a decision best made in conjunction with an addiction psychiatrist familiar with the individual case and we recommend close follow-up with an addiction psychiatrist in the period after a patient tapers off psychiatric medication.
Author: Jonathan I. Ritvo, MD, CeDAR Medical Director
Many individuals admit to treatment with a complex history of use, health concerns, history of trauma or loss, and may just be starting to understand the nature of their disease. In recognizing our patient’s individual concerns, while meeting the highest level of care, CeDAR offers a Multi-Dimensional Assessment approach to treatment. Individuals are assesses and evaluated during every step of their care, beginning at admission to alumni support following discharge.
Providers complete an assessment of Axis I and Axis II disorders, with special attention given to obtaining an individual’s history by completing thorough background interviews, reviewing medical information, gathering collateral information from family, friends and employees, reviewing job performance, performing laboratory evaluations and pertinent psychometric testing. Providers meet with the individual and employ current evidence-based assessments to discern the needs of the person, overall health and recommended interventions. Providers include psychiatrists, physicians, psychologist, case managers, counselors, chaplains, admission specialist, and behavioral health workers - all who specialize in addiction.
CeDAR recognizes the limitations of an assessment during early recovery (i.e., detoxification and PAWS), and acknowledges challenges within the assessment process; however, assessments during this stage of recovery can offer insightful information regarding patterns of behavior, reasons for use, potential obstacles for relapse, and establishes a baseline of functioning, like a “snapshot” of the person. This assessment of skills, health, behaviors, and beliefs can be indicative of the individual’s motivation for treatment, stage of change, and serve to compare progress at a later date. Furthermore, information gleaned through the assessment provides valuable information regarding personality characteristics, interpersonal dynamics and insight into the nature of the disease.
Our multi-dimensional assessments offer data and serves to provide a foundation to begin collaboration between providers and the individual to develop their customized care plan. Assessments are not just a one-time event, but the start of a therapeutic relationship that drives the direction of treatment.
Author: LaTisha L. Bader, PhD, LP, CeDAR Psychologist
CeDAR Alumni Recovery Support Services (CARSS)
As CeDAR has moved away from the acute model of treatment into a more evidence based long term approach one of the key components to our treatment model has become our Recovery Support Services. This service fits well within the continuum of care as a Recovery Oriented System of care, a concept that urges us to consider treatment as preparation for a life in recovery rather than an isolated acute incident.
When a patient enters treatment at CeDAR, they are assigned a Recovery Support Specialist who will work with them during their stay to build a recovery plan and then will stay in touch with the patient at regular intervals after their discharge. The plan that the CARSS team helps the patient put together addresses issues such as physical health, leisure activities, family/friend relationships, social situations, work/school, etc. This plan differs greatly from the aftercare plan that is put together individually for each patient by their therapist and treating doctors in that it is not clinical in nature, the recovery plan deals with their real life issues and helps to create a framework for living outside of treatment. Being aware of and proactively addressing these issues inside of treatment helps to minimize stressful situations that can result when a patient is back in “the real world.”
Another valuable part of treatment is the education that takes place around 12 step groups, sober communities, and resources that can be utilized in the community. The CeDAR CARRS team will help the patient realize their current resources, which we call Recovery Capital and to use that capital in their sober lives. This includes internal resources such as core values and beliefs, and well as external resources such as a supportive family/friends and material capital.
CARSS also conducts weekly “Recovery Is Discovery” classes open only to CeDAR alumni that address these specific topics. The resources provided by our CARSS team gives our patients a better opportunity to build the initial foundation for recovery and then to sustain that recovery throughout their lives.
Additionally following primary treatment the CARSS team follows up with the patient at various intervals to offer “peer support”, covering simple encouragement, help in connecting with other alumni in recovery, and practical “next step” solutions to living life. Former patients are also encouraged to reach out to their Recovery Support Specialist at any time he/she needs to; we remain there for our patients even after they leave CeDAR.
The alumni group, run by our CARSS team, holds various events to keep our patients engaged in CeDAR and the recovery community. Weekly alumni support groups occur every Thursday evening where alumni are welcome back to share their experiences with patients in their final 2 weeks of primary treatment. It’s invaluable when a patient can hear real stories about an alumni’s recovery journey. This kind of true peer support is a rare thing inside of comparable programs and something that we are very proud of. We also conduct quarterly workshops designed to educate alumni and their families on critical subjects such as communication skills, living life on life’s terms, and spirituality. Recreational activities such as winter sports, annual picnic, and a holiday party to name a few.
Recovery is a lifelong process and our CARSS team is there to help CeDAR patients while in treatment and for the long haul.
Author: Michael Holtzer, B.A., CAC II, CARSS Coordinator
One of a patient with chronic pain’s most persistent fears is that others will believe that their pain is exaggerated, not real, or “all in their heads”. For the patient with both pain and addiction, this fear is often magnified. Here at CeDAR, we know that patients with pain often struggle with the idea that “I’m a person with chronic pain that is out of control….I’m not an addict”.
Working as a team, CeDAR’s addiction and pain management professionals support this individual’s treatment needs using an interdisciplinary approach that includes safe detoxification from problematic and addictive substances, prescribing evidenced-based effective medications and utilizing a variety of non-pharmacologic methods of pain control and coping skills.
For some individuals, use of prescribed opiates such as Vicodin or Percocet may be involved in their road to addiction. One patient recounted “it felt like a blanket had put on my emotional pain when I took my pain medicine for my knee injury”. Unwittingly, this individual’s chronic unhappiness and a history of childhood neglect felt somehow “better” when he took his pain medication. He described not only less knee pain, but less life-pain.
For others in recovery from addiction, an opiate may be prescribed following a surgery or serious painful injury. If the recovering individual is unprepared or uninformed, the neural pathways in the brain’s reward system can reawaken the addictive process.
At CeDAR, our patient’s learn safeguards learn to prevent the catastrophic spiral into addiction accompanying an acute painful illness.
Some of these are:
1. Contact your sponsor and inform your trusted support group – perhaps even having them accompany you on your medical visits
2. Inform your addiction team of all medications that you are prescribed and inform full communications among your providers
3. Have a trusted individual hold the prescriptions for you so you are not tempted to overmedicate
4. Try non-drug therapies after consultation with your treatment provider (i.e. relaxation techniques, thermal treatments, physical therapy, acupuncture, etc.)
Without these safeguards, things quickly get out of control and what the patient believed would be a short-term use of post-op medications turns into frequent early requested refills, reports of “lost prescriptions”, having a few cocktails with the prescription to enhance the effect of the prescription effect, and finally the physician refuses to refill the opiates, fearing that the patient has developed an addiction to them. These patients then sometimes turn to street drugs, with heroin being the cheapest replacement for their opiate prescription.
In our gender-specific pain management groups, we address:
• How irrational thought patterns may be woven into the pain narrative
• Utilizing imagery for comfort
• Pain and the relationship of: interpersonal boundaries, activity pacing, and sleep
• Medications that can safely be used for pain without harming recovery
• Developing a pro-active plan for “just in case” (aka “how do I stay in recovery if I have to have surgery or am in a car wreck?”)
• Identifying your pain management resources
Authors: Patricia "Patti" Pade, MD, CeDAR Addiction-Certified Primary Care Physician
Juliana Wisher, MSN, RN, PMHCNS-BC, Clinical Nurse Specialist, CeDAR Admissions
Intensive Outpatient Program (IOP)
The CeDAR Intensive Outpatient Program (IOP) is designed to meet the needs of people seeking substance use treatment who don’t require a residential treatment but require an intermediate amount of treatment to support their recovery process. IOP programing typically consists of 9 hours of group therapy per week, individual counseling bi-weekly and random urine analysis/breath analysis monitoring. Psychological testing, addiction medicine medication management and psychiatric medication management are also provided to IOP participants as needed.
Our IOP program serves adults age 18 and older, who have a substance use/abuse treatment need and are voluntarily seeking treatment. IOP group participants may be seeking treatment for the first time, are reengaging in the treatment process or transitioning from a residential treatment setting. In addition to a world class addiction treatment experience, group participants will experience a program designed to meet the unique needs of participants who may also experience mental health difficulties and trauma related issues.
Our curriculum was developed by a multidisciplinary team including: psychiatrists, addiction medicine physicians, psychologists, clinical nurses, family therapists, addiction therapists, chaplains and case managers. Group content was developed based upon of years of clinical experience, the latest addiction research, evidence based addiction treatment methods, evidenced base group therapy content, and 12 step emphasis. Our curriculum consists of 36 group therapy sessions delivered over 12 weeks by a multidisciplinary treatment team. Participants in CeDAR’s IOP program will be exposed to a balance of lecture/teaching, traditional group therapy process and interactive treatment methods.
At CeDAR, we believe in a holistic treatment experience. CeDAR’s comprehensive IOP curriculum is geared towards addressing the biological, psychological, social and spiritual aspects of the disease of addiction.
- Biological content: neurobiology of addiction, becoming an effective healthcare consumer in recovery, medication issues, cravings, post-acute withdrawal, development of a recovery routine, nutrition, sleep issues, exercise in recovery and relaxation methods.
- Psychological content: addictive thought process, development of hope, cognitive distortions, recognition of growth, mental markers of recovery and relapse, impact of culture on recovery, gender issues, trauma and recovery, mental health wellness and development of psychological recovery capital.
- Social content: Development of social supports, self-evaluation of supports in recovery, family issues, 12 step participation, sponsorship, amends, social skills, time management, friendship and recreation.
- Spiritual content: Spirituality and recovery, service to others, prayer, mediation, differentiation between religion and spirituality, becoming connected to supports, and understanding an implementation of “spiritual principles” in the recovery process.
Treatment planning is a collaborative process involving the IOP participant, family members, outside treatment providers and the multi-disciplinary team. IOP participants can expect a collaborative, intentional and supportive experience with respect to the development of a relevant, individualized and caring treatment planning process. At CeDAR we recognize that the development and implementation of treatment goals into each participant’s treatment experience is vital to achieving the best possible treatment outcomes.
Family participation in the treatment process is crucial to providing IOP participants with the best possible outcomes. Given that fact, family members are invited to participate in a week long family program on site.
Q: What is the cost?
A: $6,120 is the cost for the program. Cost includes all group and individual sessions.
Q: Is psychiatry and psychological testing available?
A: Yes, for an additional cost.
Q: When do groups meet?
A: Patients have to group options.
Group #1 is held Monday, Wednesday and Friday from 5p-8p.
Group #2 is held Monday 1p-4p, Wednesday 5p-8p, Friday 1p-4p.
Author: Jay Voigt M.Ed, LPC, CAC III, CeDAR Outpatient Program Supervisor
Coping Skills Group: Integrating Dialectical Behavior Therapy with the Twelve Steps
Dialectical Behavior Therapy (DBT) was initially developed for severe and chronic multi-diagnosed clients. Since its inception, there has been extensive research on using DBT with a variety of populations, such as those with personality disorders, post-traumatic stress disorder, self-harm behaviors and suicidal thoughts, anxiety, eating disorders and substance use disorders.
In light of the research and descriptive articles written describing the success in using DBT in substance abuse treatment, many treatment centers have begun using this treatment modality. Addiction literature has also clearly demonstrated the utility of Twelve Step programming in supporting recovery. DBT and Twelve Step philosophy have many conceptual similarities. Both are empirically supported treatments. Because they both work well, it makes sense to integrate these two effective approaches.
At CeDAR, the Coping Skills group utilizes the curriculum that Bari K Platter and Osvaldo Cabral (both CeDAR staff) developed, Integrating Dialectical Behavior Therapy with the Twelve Steps. This curriculum was recently published by Hazelden and is used in many substance treatment programs throughout the United States.
In Coping Skills Group, patients learn and practice skills to utilize when they experience unwanted emotions or distress. The goal of the Coping Skills Group is to provide patients with the tools necessary to live a successful life in recovery. In addition to learning and practicing skills in group, all CeDAR patients receive a Participant Workbook that includes over eighty Coping Skills Worksheets. These worksheets assist patients in learning more about how to use the skills learned in group and to reflect upon how they can successfully use those skills after discharge.
Ms. Platter also offers individual DBT coaching sessions for those patients who will benefit from developing an individualized approach to utilizing the skills learned and practiced in the group setting.
Authors: Bari K Platter, MS, RN, PMHCNS-BC, CeDAR Clinical Nurse Educator
Osvaldo “Ozzie” Cabral, MA, CAC III, CeDAR Team Leader, Men's Treatment Services
Cedar is a Tobacco Free Facility
On February 14, 2013 CeDAR transitioned to a TOBACCO-FREE treatment center. The evidence for our decision is clear and irrefutable. Tobacco use accounts for the premature deaths of 443,000 persons annually in the United States, with an additional 8.6 million disabled from tobacco-related diseases. Exposure to second hand smoke results in an estimated 3,000 deaths due to lung cancer in nonsmokers, 46,000 deaths due to heart disease in nonsmokers, 150,000 – 300,000 lower respiratory infections in infants and toddlers. Our transition to being a tobacco-free treatment center reduced patient exposure to the deadly effects of tobacco, as well as reduced nonsmoking patient, visitor, and staff exposure to second hand smoke.
Nicotine is one of the most highly addictive substances. Our goal is to promote positive health behaviors and help reduce nicotine addiction. Allowing individuals to continue to use the maladaptive and unhealthy coping skill of tobacco use during treatment robs them of the opportunity to learn and incorporate healthy coping skills. Also, exposure to tobacco using patients increases the rate of relapse to tobacco use in recovered patients. Our transition to being a tobacco-free treatment center has provided patients with increased confidence in their ability to lead a tobacco-free life following discharge from our treatment center. Our transition is also preventing the initiation of tobacco use or relapse to tobacco use as a maladaptive coping skill during treatment. Since CeDAR has transitioned to being a tobacco-free facility, our rates of patient relapse to tobacco use have plummeted and the rates of patients and staff in recovery from tobacco who are triggered by tobacco use has also plummeted.
Studies show most smokers want to quit and they can quit. Nearly 80% of persons with a substance use or co-occurring mental health disorder intend to quit -- the majority within the next month. Although many patients want to stop using tobacco, they are not confident they can stop using tobacco. CeDAR wants to help those who do use tobacco products gain that confidence while here for their addictions treatment. We know nicotine dependence is a chronic, relapsing disorder often requiring multiple attempts before individuals quit for good. We also know proven treatments that significantly enhance quitting tobacco use do exist. In working with clients that smoke or use other tobacco products, CeDAR will first assess their stage of change. Individuals who are not interested in quitting tobacco will be offered nicotine replacement products to prevent symptoms of nicotine withdrawal. Individuals who express a desire to cut-down or stop their tobacco use will be offered a combination of individual and group counseling sessions as part of our regular treatment program, along with Food and Drug Administration (FDA) approved smoking cessation medications, including nicotine replacement products (patches, gum and lozenges), Buproprion SR (Wellbutrin, Zyban) and Varenicline (Chantix). Patients are consistently surprised at their strength and ability to be tobacco-free. Since CeDAR has transitioned to being a tobacco-free facility, the tobacco quit rate for our patients at discharge is 9 times higher than it was prior to our transition.
Quitting tobacco use during addictions treatment enhances rather than compromises long-term sobriety. Traditionally, patients and care-providers have been concerned that asking a patient to give everything up at once would be too hard, distract attention from the primary addiction, or result in relapse. However, research indicates smoking and other tobacco use cessation interventions provided during addictions treatment are associated with a 25% increased likelihood of long-term abstinence from alcohol and illicit drugs. We believe that the absence of tobacco use increases the opportunity to practice recovery behaviors in a real-time setting. This further strengthens the treatment of the primary substance use disorder, rather than distracting from it. We believe that our tobacco-free transition more effectively aligns our daily treatment program with not only our goal to give each patient we work with the greatest chance at success in recovery, but also our Mission of “providing a foundation for life in recovery with compassion, respect and hope.”
Author: Laura F. Martin, MD, CeDAR Attending Psychiatrist
For the majority, gambling is a harmless social activity with costs no greater than other amusements, such as movies, sports events, concerts. For some, gambling can become a progressive disease with similar phases and stages as substance abuse. Money is not the addiction; it is the fuel for the gambler’s “fantasy” (escape into the dream world of what’s going to make life better...extravagant gifts for family/friends, mansions, world travel, respect derived from money, etc. ). Winning big is worse than losing big because the rush is so high and can’t always be reached again. Losing is sought out because the “chase” is what produces the high. There is always a bigger dream to chase.
Although historically treated as an addictive disorder, a gambling problem was previously classified by the American Psychiatric Association’s Diagnostic & Statistical Manual of Mental Disorders(DSM IV-TR ) under impulse disorders not elsewhere classified rather than chemical dependency disorders. There was only one (1) level of severity for pathological gambling. The new DSM V manual has now included pathological gambling as an “addictive disorder.” This reflects research findings that the gambling disorder is similar to substance -related disorders in clinical expression, brain origin, comorbidity, physiology, and treatment. A family history of substance abuse, history of trauma, chronic pain, and an existing personality and/or other co-occurring psychiatric disorder(s) are important risk factors for addictive gambling. The majority of addictive gamblers have more than a single clinical problem, and these issues intertwine in complex problems.
The growth in types of legalized gambling and access to Internet gambling have increased the opportunities for individuals who previously could not gamble due to age, disabilities, or other limitations. Gambling is an isolating activity, not a social one. Gambling is insidious and the decline is rapid. Addictive gamblers are prone to depression & suicide; the crisis is ominous financial debt.
CeDAR’s clinical assessment contains the Gamblers Anonymous 20 Questions questionnaire as a routine screening tool for all patients. Most addictive gamblers will answer “yes” to at least 7-of these questions. The South Oaks Gambling Screen (SOGS) has been the most widely used tool for more specific information. Whenever a screening indicates significant concern, the patient is asked to provide a more in depth self-evaluation of his/her gambling behaviors and consequences. Referral sources and authorized collateral contacts are essential to determine treatment direction.
• Financial concerns must be immediately addressed in treatment (whether outpatient or residential). The reality is that the addictive gambler cannot have cash in his/her pocket or access to checking accounts or credit cards. A strict allowance with accountability for each cent is recommended. After 90-days clean, Gamblers Anonymous offers a “pressure relief” group to manage/budget and work with consumer credit.
• Bringing in a spouse or parent early on is beneficial to address their financial vulnerability and ability to protect themselves financially.
Due to the diverse nature of patients with a diagnosis of addictive gambling, and the propensity of dual diagnosis, treatment is highly individualized and flexible to vary the intensity and frequency of treatment of patients diagnosed with pathological gambling as needed. During times of acute crisis when the goal is stabilization of the gambling behaviors, suicidal ideation, mental health and /or psychiatric problems, inpatient may be recommended.
Depending on the nature of the presenting problems, the patients that are diagnosed with addictive gambling benefit from an outpatient setting, seen from 1-5 times weekly, in a combination of group, family and individual therapy, psycho-educational lectures, and psychiatric consultation, GA attendance/sponsorship, assistance with voluntary self-exclusion from gambling facilities. They also benefit from increasingly less frequent service contacts yet long term supportive contacts with treatment professionals. Treatment duration will vary, and for some individuals, the maintenance or relapse prevention phase needs to be open ended and long term. Treatment works effectively by combining treatment modalities (Motivational Interviewing, CBT, DBT, trauma and grief therapy, stress management, impulse control and problem solving techniques, and the12-Steps.) The patient is require to abstain from alcohol and/or other drug use. Therapists formulate interventions that address the need to look at reality through achievable goals because the gambler has been addicted to fantasy. Medication treatments include SSRIs, Naltrexone, and/or mood stabilizers.
The effective identification, assessment, and treatment of addictive gambling, whether given as the initial presenting problem or identified as secondary to another addictive behavior, addresses the concept of dual addiction, and co-occurring disorders and problematic behaviors. The majority of addictive gamblers have more than a single clinical problem and these issues require an integrated treatment experience. CeDAR has the professional staff needed to treat the addictive gambler for the entire range of problems they experience in a planned and logical sequence at a pace that is tolerable for the patient and their families.
• Increasing preoccupation with gambling, increase in size of bets
• Boasting about winning, evasive about losing
• Gambling used to escape problems or relieve depression
• Inability to stop regardless of winning or losing, and despite constant vows to abstain
• Withdrawal from family, frequent absences from home/work
• Restlessness/irritability when attempting to down or stop gambling
• Use of alcohol, drugs, or sleep to escape
• Lying to family or others to hide amount of gambling
• Diversion of living expenses/retirement or education funds/refinancing
• Impatience with family/friends
• Reliance on others for money to relieve financial problem due to gambling
• Neglects responsibilities
• Thoughts of suicide as a way of solving problem
Similarities to Alcohol/Drug Addiction:
• Denial/Loss of control/Increased tolerance and continued use despite negative consequence
• Chasing first win/high similar to cocaine rush
• Brownouts (lost track of time) compared to “blackouts”
• Addiction used to escape from emotional/physical pain
• Low self-esteem/High ego
• Dysfunctional families
• Use of rituals
• Immediate gratification
• Withdrawal/Severe depression & Mood swings
Differences from Alcohol/Drug Addiction:
• Secret/hidden addiction/cannot be detected in a setting like drug testing
• Tremendous financial problems which require immediate attention in treatment
• Can function better at employment site
• Does not require ingestion of chemicals
• Prevention message not readily accepted by the community (lottery can be viewed as a civic duty)
• Fewer resources for the problem gambler and their families
Author: Leslie "Honey" Hays, BS, ICADC, CAC III, ACCGC, CeDAR Addiction Case Manager