Adherence in Addiction Recovery Treatment: Surrender is Scary, Yet Critical

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CLINICAL REFLECTIONS

Change, control, and compliance are terms often used in addiction treatment. So too are surrender, adherence, and recovery.

It is known that addiction is a struggle for control and relinquishing control is a critical step in the recovery journey. We are struggling to gain control over what happens to our minds and bodies when we use substances. We fight to be right, to continue to use, to end the pain of withdrawal, and to make life easier to bear. We fight long into allostasis, believing that we will one day reach homeostasis. We simply do not believe that we cannot feel euphoria one more time.

We fight like seasoned warriors for the right to use drugs and alcohol with abandon. This is the great surrender everyone talks about: laying down our weapons and admitting that we cannot control what happens when we use. That we are controlled by it.

The way clinicians work with patients during this phase is critical. When this work is not done respectfully and from a recovery-informed place, patients may either rebel or “submit” by making the motions to please others, without being fully invested. Either way, the result is more suffering—possibly even death.

Let’s face it: No one likes to recreate themselves, to admit when they are wrong, or to restart their lives. Yet, for those of us with substance use disorder (SUD), that is exactly what we are doing. We are admitting we were wrong, starting over, and creating a new identity for ourselves. That is hard work for anyone, whether they are struggling with substance use or something else.

In addiction treatment, the term compliance is often used by clinicians as a gauge for surrender into the change process. If we are “compliant,” we must be on the road to healing through conformity. Seeking “compliance” is a derogatory removal of patients’ freewill that sets them up to resist, as adults naturally seek autonomy and freewill. Inadvertently, clinicians may be setting patients up for failure by focusing on compliance and conformity instead of taking a more respectful position.

When it is perceived that a patient is stalled in a stage and at risk for relapse, overdose, or death, it can be frustrating and easily labeled noncompliant. Noncompliance, by definition, is a failure, or refusal, to act in accordance with a wish or command. Patients are not failing or refusing to comply—they may be in the early stages of change, suffering the painful adverse effects of recovery, or in the middle of a fear or shame storm. When clinicians insist on compliance, patients are often punished for the symptoms of their disease, which creates defensiveness.

It makes sense: Defensiveness comes from a place of fear, a lack of trust, and a desire to be in control. When patients surrender in recovery, it entails humility and trusting in what they are being asked to do to recover while moving forward without personal proof. Consider instead working toward treatment adherence.

Treatment adherence is defined by the World Health Organization as the extent to which an individual’s behavior, with respect to taking medication, following a diet, and/or executing lifestyle changes, corresponds with recommendations from a health care provider.¹

Treatment adherence is voluntary. It requires patients to understand the nature of their chronic condition, to have a desire to heal, and to participate. Treatment adherence is very much in line with the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) definition of recovery: “Recovery is a process of change through which people improve their health and wellness, live self-directed lives, and strive to reach their full potential.”²

Here are some tips to support you in encouraging treatment adherence.

• Make use of assessments like the SOCRATES 8A. Understanding where an individual is in the change process can help you, and them, to develop hope that they can change.
• Educate patients about stages of change, the acute and post-acute withdrawal process, and new coping strategies. Knowing the lay of the land of recovery creates desire to be here.
• Make use of data. We know that technology and frequent checkins provide not only a digital tether but baselines that can help you and the patient create a new, exciting life vision to walk toward. That ends the suffering of running from pain.
• Help patients connect with others who have lived experience of recovery, not just addiction.

Treatment adherence separates those with long-term recovery from those who experience only brief periods of remission. Seeing an individual through the lens of self-direction recalls the recovery care team and the patient to hope, direction, and freedom from SUD. Ultimately, it supports a patient’s new belief that recovery is greater than addiction—and it is possible for them, too.

Ms Dolan is CEO of Dolan Research International. Ms Voegtle is director of clinical programs at TryCycle Data Systems.

References

1. Adherence to long-term therapies: evidence for action. World Health Organization. 2003. Accessed May 15, 2023. https://apps.who.int/iris/handle/10665/42682

2. Recovery and recovery support. Substance Abuse and Mental Health Services Administration. Updated April 24, 2023. Accessed May 15, 2023. https://www.samhsa.gov/find-help/recovery?gclid=CjwKCAjw1YCkBhAOEiwA5aN4ARmQh0HGyaNyGHujB3B-IiRBZcGv4ZKwNhvLl-rRJpPZkC2Vu0yPjhoCNNYQAvD_BwE