The Sustainable Recovery Handbook:
How to Beat Addiction and Have the Recovery and Life of Your Dreams
by Keith Keller
Chapter 6: You in Rehab
Remember those things I said other people might do? Like being the class clown, the ice cube in the warm liquid, or behaving like children? You are not exempt. I warned you that your addiction would not go quietly.
One of the byproducts of the addictive lifestyle is an accumulation of habits, poor coping skills, and even personality traits that will not serve your highest interest in a life of recovery.
Addicted to Drama
You became addicted to more than a substance. You became addicted to behaviors, but more precisely, you became addicted to the feelings that resulted from those behaviors. This is an important fact that many people miss on the road to recovery, but it is true for most of us. We became addicted to the drama that our addicted lifestyle produced.
As a group of people, we are preoccupied with how we feel, and as we fell deeper into addiction, we needed more and more of our substance to get the same effect. Constantly craving more stimulation, we achieved a similar effect with our natural brain chemicals. The conflict of a senseless argument, the twisted satisfaction of getting your way through manipulation, and the thrill of the chase to score drugs all served to give us that little rush. These behaviors pushed little buttons in our brains’ pleasure centers to the point where we would instinctively repeat them, over and over. This action is rooted in chemistry no less than drinking vodka, snorting coke, or shooting dope is. The only difference is where the drug is produced— in this case, right within us.
So, when we detox off alcohol or heroin and get our bodies normalized, our addictive issues are far from resolved. Thinking that it’s only necessary to avoid picking up alcohol or drugs again is simplistic. Everything we do, every behavior we have, is based in body chemistry, so the internal chemical environment of the body becomes as important a consideration as anything artificial we might put into it. The substance itself was merely a part of the problem. You are addicted to a way of being.
This might serve to shed some light on all the complicated and intense feelings you’re experiencing as you move through and beyond the detox process. You will be inclined to act first and think later, but I encourage you to do the opposite. And, if the staff is doing their jobs at that rehab, you should be hearing something similar from them. To varying degrees, most alcoholics and addicts have literally damaged their brains. Impaired concentration, impaired memory, sleep disturbance, mood disturbance, and emotional dysregulation are symptoms of post-acute withdrawal syndrome (PAWS), which can last for months. As horrible as this sounds, it’s actually good news. Having an explanation for the symptoms and problems is reassuring. Also reassuring is the fact that your brain will heal itself, if you give it a chance.
Anxiety is another issue that plagues most people before, during and after the detox phase, though it is more of an acquired, even learned, condition than a type of brain damage. I have wonderful news about anxiety, but you might not like it. Ready? ANXIETY IS PART OF LIFE.
I know, not what you want to hear, but seriously, there is good news. Anxiety is a bodily manifestation of a mental, emotional, or psychological state. Your body is reacting to your thoughts in the form of real physical symptoms. Elevated blood pressure, rapid pulse, sweaty palms, sweaty everything, dry mouth, stomach in knots, heart feeling like it’s going to explode out of your chest! These are the real effects on your body that your thoughts can have.
So, where do they come from? Usually, something happened in the past. Something went horribly wrong, and you never forgot. Subconsciously, or even consciously, you fear that it will happen again in the future. Remember the fight-or-flight response? When you call up the thoughts of that thing that happened in the past, you throw your body into survival mode. Your body does not know the difference between something that you are just thinking about and something that is happening in your environment right now. That’s how powerful our thoughts are. All those real physical symptoms are exactly what happen when we produce adrenaline, and all it takes is the wrong thought.
What about when I’m not calling up any thoughts? The anxiety is just there. It always has been, and I fear that it always will be. Lightbulb moment: maybe I’m anxious about my anxiety?
Let’s consider that for a moment, because the reality is that, for many, this is the reason we’re here having this whole discussion in print. Wait, what? Whether we realized it or not, we drank, used and got high because we were anxious, or at a minimum, anxiety is pretty heavily at issue in the root cause of addiction. Not just randomly anxious about a stressful situation, we suffer from something deeper, something that became a part of us. As previously described as a result of having the fight-or-flight response over time, we experienced a progression of anxious mood to anxious temperament to anxious personality components. This actually modified the way our brains work, something we’ll explain in detail down the road, but for the moment, what that means is that the first time we caught a good buzz, it felt like the warm hug we had been waiting all our lives to receive.
Where did this come from? We’re not here to assign blame, but understanding how this happened is useful. For example, I grew up with a divorced single-parent mother, who loved me very much. However, she drank, and had her own anxiety and insecurities. She shared way too much information with her son, the eldest child. As a 10-year-old, at the age where I was starting to think about things besides myself, I didn’t need to hear about the mortgage, taxes and heating bill. I actually lay awake at night, worrying about not only myself, but my sisters and mother as well. I was also quite sensitive to my mother’s emotional pain.
Worrying about things that I had no control over had two results, both short-term effects with negative long-term consequences. Since I could neither make it stop nor escape from it, it caused me to feel anxious and, as best I could, to check out from it mentally and emotionally. Later, as the anxiety continued to take hold, checking out took the form of drinking and drugging.
Okay, let’s take stock of the situation. Something happened in the past. You’re afraid (perhaps subconsciously) it’s going to happen in the future. Is it happening right now? Chances are it’s not. As was the case with me, your anxiety itself may be the most anxiety-provoking thing in your life.
If it’s part of life, why is anxiety such a problem for recovering alcoholics and addicts? Because our go to solution was tuning out the discomfort with the substance. A byproduct of our chemical mood modification, the anxiety got dulled down along with our other senses. Take away the intoxicating substance, and we’re left with a severely reduced tolerance to stress and anxiety.
There’s the issue of coping skills. Regular folks have anxiety all the time, and they just seem to deal with it without checking out. Look at history, and how hard life was. Living in the Dark Ages was probably some intense anxiety. Or, in the Old West, the settlers were probably anxious about being attacked by Native Americans, who were anxious about the influx of illegal aliens. Being anxious and vigilant served a purpose, but they probably never said, “Hey, Jeremiah, break out the Ativan, I’m feelin’ a might anxious.” That’s the purpose of anxiety, to help us survive. We addicted folks don’t seem to get the knack of handling anxiety. Every time we have the option of building some tolerance, on the one hand, or enjoying better living through chemistry, we opt for chemistry.
Given choice, reality lost every time. Even before I quit drinking, I suffered from anxiety so crushing, I could barely force myself to get out of the car and walk in to my job in the morning.
The solution to lack of tolerance is to build tolerance. I know, that’s good news because it’s fixable, but bad news because it requires effort. Compare this to strengthening a muscle. To build that muscle, you make it work against resistance. To build tolerance to anxiety… you need to push yourself to tolerate it when you feel anxious.
Chemical Mood Modification
This is a perfect segue to the topic of PRN medication. While you are in a rehab facility, your doctor has ordered a medication regimen for you. This consists of scheduled medications—those you receive at specific times, and what are termed PRN (from the Latin “pro re nata,” or as needed) medications—which are available to you at the discretion of the nursing staff, within set guidelines, if you meet the intended criteria. PRN/as needed medications include all the over the counter (nonprescription) things we take at home for aches and pains, allergies, coughs, etc., which in any kind of facility require a doctor’s order. Rather than the nurse calling a doctor for an order every time someone gets a headache, these medications are usually prescribed as a package ahead of time.
Most detox protocols include PRN medications. These are designed to be given (at the nurse’s discretion according to set guidelines) if withdrawal symptoms are persisting despite the scheduled medication. PRN medications are also often ordered to be given for anxiety. This is a huge gray area. As a nurse on a detox unit, I favor medicating detox clients for measurable symptoms of withdrawal; I favor conservative anxiety medication for detox clients with histories of trauma and other related clinical conditions. However, for situations involving nonspecific subjective (how they feel) complaints of anxiety, I think medication should be used after other measures have been attempted and failed.
Alcoholics and addicts are relief-seeking missiles. From my personal experience, reality was to be avoided at all costs. In our culture, we feel entitled to better living through chemistry. The go-to fix for any negative emotion is medication.
Simply put, this is where the line gets drawn in the sand.
A new way of life requires new thoughts, habits, motivations and behaviors. Are you feeling anxious? What are you anxious about?
As a nurse hearing frequent requests for anxiety medication, my first question was always, “What are you anxious about?” Literally, in four out of five instances, the clients did not know why they were anxious. While a legitimate reason for anxiety was a whole different conversation, what I usually heard was something along the lines of, “I just am.”
The nurses on your detox unit do you no service by simply handing you powerful, mind-altering medication on request. In fact, it’s quite the opposite. You are not going to climb out of the hole of addiction by feeding anxiety that way. Without looking at the anxiety and its source, it will never get better. Without developing and enhancing coping skills (I know, that word again), or, in other words, following your care plan, you are going to be just as helpless on the day you leave detox as you were on the day you entered detox. Sadly, the nurse who just hands you drugs on request doesn’t know better, or worse, just doesn’t care enough about you to help you learn something about yourself and advance the cause of your recovery.
You need to ask yourself, “By requesting a PRN medication, am I asking a nurse to do for me what the dealer and bartender did?” Is your motivation to make your anxiety go away, or maybe catch a little buzz? Be honest; remember it’s just us here. Is this about anxiety, or is it about the medication? Or is it about feeling as if you have control over something? Tuning out reality was sometimes the only measure of control we had.
After the question of where the anxiety comes from goes unanswered, something revealing typically happens. I would always attempt to first educate clients about anxiety, and then provide them with nonpharmaceutical ways to help. Someone whose motivation is to be free from anxiety is usually interested. Someone who only wants to modify his or her mood chemically, sometimes labeled as a “med-seeker,” is usually not interested in gaining insight.
And again, in cases of documented clinical history of trauma, abuse, neglect, or other unique circumstances, due consideration must be given. Unfortunately, most nurses just give medication without regard to circumstances, history, goals of the care plan, or the highest interest of the client. Why? Because they don’t know better, and because it’s easier. Superficially, it’s true that they are alleviating suffering, but it’s only a Band-Aid. These situations require insight, experience and judgment on the nurse’s part, and also the ability to handle a situation that can escalate into a confrontation.
I explain what anxiety is, and that handling anxiety is like developing a muscle, that one needs to build tolerance. Then I suggest the client attempt to hold out for 20 or 30 more minutes by utilizing a coping skill, even if it’s just a diversionary measure, such as reading, watching TV, or engaging with someone (who is possibly also struggling) in conversation. If that doesn’t work, we’ll try the medication.
This attempt on my part usually ends in one of two ways. If someone is preoccupied with chemically altering their consciousness, which means they would be relapsing on the outside, they will probably curse at the messenger (me) and storm off somewhere to complain to anyone who will listen. However, if someone is motivated to get better, attempts to absorb the explanation, and tries the suggestions, more often than not, they do not return for medication. Generally, I will see them an hour later and ask how they are doing; the positive response is usually something like, “Hey, I got through it!” (Hell yeah, fist bump or high five.) To be continued.
Focus is so important. Recovery and the goal of beating your addiction have to be your constant objective. It’s too easy to get sidetracked. Something like the anxiety issue can suck away your attention and energy into a useless little power struggle with staff people who are going home after eight hours and won’t think about it again. You, on the other hand, might spend the rest of the day and night back at square one in survival mode over a worthless conflict.
The anxiety/PRN issue is just one of numerous little booby traps that might arise. The common denominator is that your energy will be sucked away from your primary goal of recovery. Your addiction to your drama, your old way of being, will come in a hundred subtle forms. You can spend your mental energy analyzing and justifying them, or you can recognize them for what they are: the old habits that won’t work in your new life.
So, let’s peel it back a little bit. It’s useful to understand what’s happening, and for the sake of argument, we’ll say you’re observing someone else experience these kinds of issues on the unit. Behind most of these behaviors is some kind of unmet need. The same might be true of the anxiety response.
The client who refused to have a discussion about anxiety and left in a huff, angry because he didn’t get what he wanted on his terms in his timeframe, still needs help, but it will need to take a different form. At the time of the negative interaction with staff, he was emotionally charged. This effectively shuts down his ability to reason, absorb information, and actually learn something. The only thing that’s going to get through at that moment is something of equal emotional charge. In other words, if he’s yelling nonsense at the nurse, he’ll understand if someone yells back at him, but that’s not going to help. Ironically, the compassion and understanding he needs most wouldn’t even register in this heated moment. He needs some time to chill out, and should then be re-approached.
Despite his appearance and behavior, this troubled client might be feeling isolated and lonely, in addition to scared. This is all based in his past, in his personal version of that thing he couldn’t control or escape from, and therefore tuned out. Assisting him to understand, or possibly even acknowledge, the reason for his behavior, and the walls of protection he keeps in place, if only in the form of a mostly one-sided discussion can do a lot to benefit someone who has painted themselves into a bit of a corner. The same is true of reminding him that the things on the first page of Chapter 1 in this book were never truer—that facing addiction is powerful and courageous, and that he is worthy of acceptance, compassion and love—and that those basic fears are common to all people, not just addicts. Right in that moment, he has an opportunity to do something uncommon. He can face his fear of the unknown, choose not to repeat the past, and instead start to change himself into a new and upgraded version.
For the client in rehab, the journey from darkness to light is scary and confusing. Everything feels like a contradiction. While still unable to comprehend or accept the backstory and causes of their addiction, they are left to deal with its effects. The discomfort of faulty instincts makes that which is in their highest interest feel nothing remotely like the compassion they sorely need.
Know that there is hope, but understand that it will get intensely dark before it finally gets light; it needs to all fall apart before it can fall together. If you can hold on through all the drama, the addictive tendencies, the bad feelings and behavior, you will finally experience a moment of clarity as a result. In that moment, you’re going to feel something amazingly powerful. You’re going to feel hope, because you’re going to realize in that moment that change is possible. Sometimes, we actually need to believe things before we can see them.
The value of your time in a rehab facility is directly proportionate to the amount of effort you put into it. The harder you work, the luckier you will be. Avoid the pitfalls where you can; learn from them if they happen. In addition to being a blank slate, be the tree that bends, not the tree that breaks. When things feel overwhelming, remember that it’s only a snapshot in time in the long span of your life, and that you are doing something extremely important for the quality of that life to follow.
As you move beyond crisis and survival, you will start to sense the possibilities ahead of you. Not fearful, not anxious, but enthusiastic and excited, you can actually see some light at the end of the tunnel. This is the state of creation, and a new life is yours for the making.