‘The challenge of being a professional [is that] you need to be the expert, you’re the go-to person, you’re the decision-maker and nobody wants their doctor to say, “Well, gee, let me call my AA sponsor and see if you have a heart condition or not.” They have to be right.’ Why do doctors, airline pilots, pharmacists, nurses, lawyers, clergy and other professionals need to be in an addiction program created just for them? Because their intellect can work against them in treatment, Jamie Deans, Executive Director of Professionals Treatment at Promises, said recently on the “Detailing Addictions” radio program with Dr. Susan Blank. “Physicians often think they’re at [a treatment evaluation] to consult on their own case,” Deans said. “Each one of them tends to think that they’re very special and very different and they do have this history of accomplishment. They believe that if we just give them the information, they’ll ‘think’ their way through it and be done in two or three days,” Deans said. “Of course, the treatment process is much longer than that.” Professionals tend to be people who have functioned and gotten where they are in life by using their intellect to read, understand, synthesize and utilize material, Deans said, which makes their cases very different from that of an 18-year-old who may have gotten intro drugs very early in life. “We try to meet the professionals where they are,” intellectually, Deans said.
How the Promises Program Works
“Our process is that with every client who calls, Deans said, “we’ll do an hour-and-a-half pre-admission interview with Dr. Greg Skipper,” an MD who has worked in professional health, impairment and occupational and addiction medicine for more than 30 years. Dr. Skipper is going to spend a lot of time with them, finding out about their history, finding out about their usage patterns – is it just alcohol, are there drugs involved, when did they start using, what are the stressors in their life that’s causing them to use? We’re also going to call the referring clinician if there’s a therapist or doctor involved and get all of their prior treatment records. And so we have a good idea of the client’s basic issues before they get to us. “We start the first day by having them do a battery of psychological tests. We use personality tests, Rorschachs. They will then spend four to six hours with the psychologist who will take Dr. Skipper’s pre-admission interview and go even deeper into it and find out who are some of the people who were involved in the incidence of this person’s life. They’re what we call ‘collateral information providers.’ The psychologist will call those collateral information providers because we want to find out how the patient got there, how does what the patient says match up with what the other people in their lives say? Do they see the same person? More often than not, they’re very different stories. That’s the first part of the process, the psychologist’s review and the psychological testing. ‘The physicians often come in with very complex stories about how they know their drug tests have been positive for three months but it really has more to do with their metabolism, these very complex stories….’ “Then we’ll have one of our addiction psychiatrists sit down with them and do a complete psychiatric evaluation. We’re looking here to find out if they have co-occurring disorders, depression, bipolar disorder, personality disorders, mood disorders, and what we’re finding increasingly is that few people come with the just straight chemical dependency issues. A lot of treatment centers can’t diagnose this way because they don’t have the qualified personnel to do it. A lot of times, these underlying psychiatric issues are what is driving the addiction. A lot of people start using substances to self-medicate. “Dr. Skipper will then do an additional addiction medicine assessment based on the other information that we’ve gotten. We also like to have them sit in a group with our other clients, which helps us see how they function in a social setting. What we’re looking for is how much personal insight do they have, how willing are they to self-disclose issues in their lives? And then for our health care professionals, one other element we have them do is sit in a group with physicians who have already been through treatment and are in their five years of monitoring. The doctors, they think, ‘Oh, finally I’m going to be with my peers and they’re really going to understand what’s going on.’ The physicians often come in with very complex stories about how they know their drug tests have been positive for three months but it really has more to do with their metabolism, these very complex stories, they’re thrilled to see their peers who are finally going to understand what’s happening. If the peer group thinks that there is nothing wrong, they’ll say so. But more often than not, they’re, like, ‘Get a grip. You have the same story I did.’ They help break through that crucial barrier of denial. Getting a client to agree to treatment for 30 to 90 days is a very high barrier to get over. One of the things we recommend to people is that if they’re not willing to commit to that, we suggest they go for the three-day evaluation, see what the experts say, and make a decision at that time.”
Origins of the Promises Professionals Treatment Center
The model was created by Dr. Douglas Talbott, founder of Talbott Recovery, who came up with a model for treating impaired health care professionals with substance abuse issues and it’s the only model to date that incorporates three things: An intensive diagnostic evaluation that looks at clients from medical, psychiatric and psychological perspectives and includes much more evaluation than is done by a standard program and much more intensive psychological tests. Then it involves highly individualized treatment with a lot of psychotherapy in addition to group therapy, which is the heart of all addiction treatment programs to help clients find the commonality of their experience. “Dr. Skipper wrote the definitive study on this. What he found was that physicians who completed their five years of post-discharge monitoring and screening, at the end of seven years, 87 percent of them were still sober. We have what I would call ‘documentable sobriety.’ ” What also differentiates Promises’ Professionals Treatment Program from the others, Deans said, is the continuing care. “You really need to have about five years of continuing care following your discharge from a treatment program. Most treatment centers say, ‘We’ll do it for six months and see how it goes.’ But Dr. Talbott realized that people need to be accountable and responsible for their recovery. And so when you hear treatment center outcomes, when they quote them, most of them are anecdotal. They’re really just guessing at what their outcomes are. And because there are public safety issues around healthcare professionals, you want to make sure your doctor is actually sober if he’s going to take out your appendix. So what we have is five years of discharge monitoring and random drug screening. We have every one of our clients do that, whether they’re a healthcare professional or not. That is the model: Evaluation, individualized treatment and post-discharge monitoring and screening. Dr. Skipper wrote the definitive study on this. What he found was that physicians who completed their five years of post-discharge monitoring and screening, at the end of seven years, 87 percent of them were still sober. We have what I would call ‘documentable sobriety.’ We had random drug tests to prove that they were sober. I would tell you that any treatment center that quotes you a figure, even 30 percent, is probably kidding themselves. The reality with addiction is that, like a lot of other diseases, diabetes, obesity, high cholesterol, things that require human beings to stay on a program where maintenance is required, we’re just not very good at it as a species. We’ll do it for six months, maybe a year, and then we tend to think ‘OK, I’ve got this now.’ ” When Dr. Skipper and I created this program, we wanted to take the best of what’s already been done and update it. The neuroscience of addiction has been growing at leaps and bounds over the last decade. We wanted to use what had been done before and add in the newer techniques while still keeping very faithful to the 12 steps. There is no more successful program than 12-step recovery, and it’s free. Where else can you hear that in today’s society? It’s free.
“We believe that the assessment process is a critical part of treating any alcoholic or addict. If you went in for any health-related issue, they would do blood work, they would do tests if you were having trouble with your liver or your lungs, because what they want is data to be able to compare the individual patient to everybody else. Every client who comes to Professionals Treatment at Promises, whether they’re a healthcare professional and are there because their licensing board is sending them, or a business executive, everybody should have a rigorous evaluation because it’s an important diagnostic tool. It becomes the foundation for the treatment plan. It’s our belief it should be the standard of care everywhere. The issue with that is, for low-cost programs, it does require a certain amount of expertise and time and it’s not economically feasible. We actually have one of the most cost-effective evaluation programs in the country. It’s $3,000, actually well below our cost. We do it because we want to induce people who aren’t sure if they have a problem to come to treatment at a reasonable rate. About 70 percent of the people who come to us for an evaluation are diagnosed with having some form of chemical dependency. Not all of them require the residential level of care that we provide. Some can be treated at home by their therapist or an intensive outpatient program. Part of the reason that number is only 70 percent is that with physician health programs, if a physician gets a DUI, they have to go for an evaluation That doesn’t indicate at all that they have a substance problem. If could have been a wedding or just bad judgment.
Chronic Pain and Sex Disorders
“We include in both our assessment and treatment regimens chronic pain and sexual disorders as well,” Deans said. “The thing about chronic pain is that you really need a hospital to help you parse out what is real pain and what is pain caused by the fact that somebody has been taking their pain medication for so long that they feel like they’re in pain, but it may no longer be caused by a physical source. We work with Dr. Joshua Prager, who runs the chronic pain management program at UCLA Hospital. There we have the entire UCLA medical center to do all the imaging and the medical aspects of whether this pain is real or perceived. We integrate that into our three-day evaluation, it usually adds an extra day onto it, and whether the pain is determined to be real or perceived, they have a program to help people manage that. If it’s not a real physical problem, we transition them through physical therapy, though psychotherapy, to make their lives productive again. If there is a legitimate physical issue, then maybe there are alternative treatments, muscle stimulators, non-narcotic pain management that can be employed. ‘One of the advantages of being in Los Angeles is that there can be eating disorders, gambling, and being in L.A., we have access to leading specialists in any field you can think of. Promises has been around for 25 years, so we’ve already identified the best of the best.’ For sexual disorders, we use the Sexual Recovery Institute, which was founded by Rob Weiss. We’ll include in our evaluation that, and, quite frankly, that is sometimes how someone’s chemical dependency issues come to light. The first thing that’s seen at work is that they’re being inappropriate with other employees. They come to us though that. We can refer them to SRI, which has a two-week intensive program for sexual disorder. We can then integrate that into our treatment schedule. Sometimes they may need full residential care. We try to find out which is the primary disorder, the sex disorder or the chemical dependency? Because many times, in the sexual disorders world, they’re actually only using chemicals to assuage their guilt and pain around their sexual behavior, which they know isn’t appropriate. And sometimes you can clear up the sexual behavior, and the chemical dependency issue goes away. If chemical dependency is the primary issue, then we’ll start with that. Once they’re sober, we can deal with the sexual disorders. One of the advantages to being in Los Angeles is that there can be eating disorders, gambling, and being in L.A., we have access to leading specialists in any field you can think of. Promises has been around for 25 years, so we’ve already identified the best of the best, people who understand chemical addiction as well, and it looks seamless to the client. They just know that they’re seeing Dr. So-and-So for their gambling. Once a client enters treatment, it’s a very rigorous program. They do 20 hours per week of group therapy and this includes cognitive behavioral therapy, which is how we integrate the 12 steps, we use dialectical behavioral therapy, somatic experiencing, affect regulation, and we do process groups six days a week. We also include things like yoga and meditation. And then they have six hours of professional-specific groups. These are professional-issues groups where they talk about things like the challenge of being a professional where you need to be the expert, you’re the go-to person at your job you’re the decision-maker and nobody wants their doctor to say, ‘Well, gee, let me call my AA sponsor and see if you have a heart condition or not.’ They have to be right. How do you balance that with being an honest, open-minded willing and humble recovery person? That a difficult balance for them to maintain. I always say that people go to their default position, and that’s to be the expert. That doesn’t serve their recovery. We also have “return-to-work” groups, and these are generally type A personalities working 80 to 100 hours a week. We try to help them set up a healthy life schedule. Doctors attend a healthcare professionals group. Lawyers go to “the other bar,” airline pilots to go “birds of a feather.” And this is where they can discuss the challenges specific to their industries. On top of that, they have two hours a week with their primary therapist, one hour with Dr. Skipper, and one hour with a family therapist. The family therapist will also be working with the family. We use a lot of video-conferencing, we tie in the families from the beginning. We help them with what is the client’s part, what is their part, and let them know that that they need to practice their own recovery. We make them aware that they’re not responsible for the client’s recovery. Toward the third or fourth week, we bring the family in for a three-day session. That adds up to about 30 hours a week. Then they have written assignments and do something we call ‘insight therapy,’ where they go and work at a public treatment center, usually for indigent folks, and there are two reasons for this. I tell the doctors, ‘think of it that you’re going as a candy striper, that you’re there to do anything but practice medicine. You’re there to learn the process of giving back, to being part of somebody else’s recovery. But they also get the idea that they’re lucky to be at a place like Promises – that one or two more binges and they might not have the resources available to do that. It’s a very intensive program.
Fitness for Duty
This is an aspect of what we call risk management. With a physician or a nurse, pharmacist or dentist, it’s really overt. Is this person safe to go back and practice their profession? Because if they’re not, they could do real physical harm or perhaps even kill someone. Our responsibility is to certify to the licensing board or physical health program that this person is psychologically, psychiatrically, medically and spiritually safe to practice medicine. And because there’s a license involved, there’s a lot of leverage. The doctor either completes treatment successfully and stays in their recovery care program, or their license will be suspended or taken away. So they have a lot of incentive to stay sober. We feel very strongly that that can be done for other professions. We have corporate accounts, and what they’re really worried about is, ‘if I take this person and have them go to treatment, how do I know they’re going to stay sober’? So we call it the creative use of leverage. One of things we do is set up contingency contracts, which is what a physician signs. It says, ‘OK, I’ll go to treatment, I can keep practicing medicine, but I agree to successfully complete my treatment and stay in post-discharge monitoring.’ That gives them both accountability and responsibility for their own recovery. And you need both of those things. With someone who is coming from a business, we’ll set up a contingency contract with that person. And there’s usually an EAP or case manager involved because the company doesn’t really want to know what’s going on with the case and you don’t really want them to know. So what you have is someone who is going to tell the company that this person is sober and they’re following their treatment plan. The only way they’ll know that they’re not is if they get a call telling them that the employee is out of compliance. So we set up a contract that says the employee agrees to complete treatment, to complete their continuing care plan and they agree to be in five years of monitoring. If they fail to do so, then the contract outlines a set of escalating consequences, small ones to begin with. Maybe they have to do an extra therapy session. Maybe we do more screening. Maybe they go back to treatment, and if it’s been set up by a company, maybe they are terminated. If it’s with a family, it could be perhaps this person has a history of driving drunk with their children – then they can’t see their children except in supervised settings. But we want to make sure that they are fit to do whatever their role is. The other aspect of this that is really crucial for families to understand is that spouses and family members are responsible only to take care of themselves. They’ve been taking care of this individual usually for years. They need to move their lives forward. The addict or alcoholic needs to take responsible for his or her own recovery. One of the things we say to spouses is that by having this person in monitoring and drug screening, you’re not going to have to wonder if they’re sober. Because, if they’re not, it’s going to come back in the tests and you’re going to be notified. And they like that. The client likes it too, because when they return home, they don’t have to worry whether people will trust them or believe that they will stay sober. This is a way they can say to them, ‘I’ll stay sober and you won’t have to keep looking sideways at me, wondering if I am.’ ” Listen to the entire interview here.