Fortifying the Powerless

Fortifying the Powerless Changing Unmanageable Lives

By Cathy Kauffman-Nearhoof, BSN, RN, CCM, CMCN, LNC with Kelly Steele BSN, RN and Liz Ruhlman, BA, CCDP

Cove Forge Behavioral Health and Drug/Alcohol Rehabilitation of White Deer Run/CRC Health is a 100-bed adult rehabilitation facility located in the Laurel Mountains of central Pennsylvania.  Cove Forge’s licensed and accredited 14-bed Detox Unit provides withdrawal treatment for a growing population of people with substance abuse addictions. 

The Detox Unit is staffed by a unique healthcare team of physicians, psychiatrists, licensed nurses, medical technicians, case managers and certified counselors. The Detox clients are diverse: all races; male and female; parents; ages 18–65; all economic categories, from high school drop-outs to PhDs, attorneys and physicians.

It may not be surprising, given recent media attention around professional wrestling and the Hollywood “bad girls,” that individuals working in arts, design, entertainment and sports have the third highest reported use of illicit drugs and alcohol. Food preparation workers and construction workers hold first and second place in self-reported substance abuse, according to statistics from the Substance Abuse and Mental Health Services Administration (SAMHSA).

Of those employees working in healthcare, 6.1 percent of them report that they have used illicit drugs during the previous month; another 3.9 percent have abused alcohol. Even NASA astronauts are not protected from the media hype, with July reports citing them as “launching while intoxicated” (though an internal investigation refuted the claim).

Care Coordination - The Bridge to Recovery
As a licensed RN and Certified Case Manager, substance abuse presented a challenging new healthcare territory to me. I had worked with patients struggling with dreadful medical and surgical diseases for decades. Little did I know that many of the patients I’d cared for in the past hid an addiction secret.

Detox clients are challenging. They often have co-occurring mental health and complex medical diagnoses. They are often sick, depressed, confused and angry. They feel victimized. Some are suicidal; many are desperate. They have lost their jobs, their families and their health. Many will relapse. Nearly 25 percent, on any given day, are homeless.  Some have hit “bottom.” Others never get there in time.

They come to Cove Forge from all over Pennsylvania and from neighboring states. They arrive to a no-frills facility. There are no beauty salons, TVs, radios, spas, pools or gourmet cooks. The only focus is recovery, what we call "life on life’s terms."

Upon their arrival at our Detox Unit, a team of Detox nurses spins into action. They triage, assess and initiate treatment plans. They obtain treatment orders specific to each client’s "primary use" and "level of risk". Most clients abuse multiple substances. They monitor clients for life-threatening withdrawal symptoms and intervene quickly.

When asked what brings a person into the Detox Unit, Psychiatric Nurse and Unit Coordinator Kelly Steele cites examples that clients reveal during their initial assessment ― “I don’t know any other way to live; all my friends use,” they might say. 

Kelly describes his most difficult client as one “who doesn’t believe they have a real problem.” Kelly’s approach is to offer support while “exploring the concept of addiction as a disease and introducing them to the first of the Twelve Steps – Powerlessness."

"Helping each client recognize the negative consequences of their use is difficult when the client is in denial," he responds.  "When I see the client embrace a change in their attitude, recognize the impact of their use, and (then) leave the unit verbalizing the need for lifelong treatment and support, I feel I’ve been successful." 

Detox Counselor Liz Ruhlman, BA, CCDP (Certified Co-Occurring Disorders Professional), enthusiastically incorporates the need for medical and recovery aftercare. She developed a comprehensive aftercare needs assessment, and she works through this and other recovery tools with each of her clients. She meets individually with each client to establish a realistic aftercare plan, thus optimizing their chances for success.

Liz involves positive clients from the CF rehabilitation community who present their own "bottom" and recovery stories on a daily basis, providing hope for the hopeless. Their message is clear ― "If I can do this, you can too."

She is not at a loss to share “success” stories from the dark side of addictions. She works from a "no time for games" philosophy with clients who often have only three to four days in Detox with no funding for continued inpatient rehabilitation. Treatment begins while the clients are suffering from anxiety, tremors, nausea, stomach cramps, guilt and depression. 

Our Detox program also incorporates daily nursing lectures. Nursing’s focus is on medical issues specific to the pathology and lifestyle of addictions, issues that include brain chemistry, heart and liver disease, sexually transmitted diseases, and medication compliance. The staff is alert to and makes use of any opening which provides a "teaching moment."

Since there is very little data available relating to the effectiveness of Detox and Rehabilitation programs, it is difficult to evaluate “successes.” The population can be transient and may be embarrassed by relapse. But without exception our healthcare team agrees that the key to successful recovery is needs-specific care coordination.

By incorporating a collaborative patient-centric model, the Detox team provides management of acute withdrawal symptoms while simultaneously planning for and coordinating crucial medical and psychiatric individualized aftercare.

Preventing Relapse – Know Your Trigger
Knowing what makes a client want to “pick up” is essential to recovery.

Helping clients identify their “triggers” is a critical element of preparing them for discharge.
According toArchibald Hart, PhD, (Alcoholism – Addiction Triggers), the two major drives which underlie the addictive processes are "excitement seeking" and "tension reduction." These processes are often set off by a specific stimulus referred to as a "trigger."

Keys to Recovery
It is no surprise that the most effective healthcare/lifestyle changes occur when an individual is driven by internal vs. external motivators. Recovery is also more likely to occur when the client admits his addiction, identifies the negative consequences of addiction, and embraces the potential of lifelong recovery through the need to change, to make better choices and to incorporate the 12-steps. Think of it this way: "If nothing changes – nothing changes."
 
Tom Callahan, Executive Administrator of Cove Forge/WDR sums up his recovery philosophy, commenting that, "You never give up on a client. It might be the 20th inpatient admission that is the one that results in recovery. You never give up."

The Detox team attempts to create a foundation from which each receptive client can begin their recovery journey. The staff constantly creates and revises tools and processes to help each client recognize, first, that their life is unmanageable and that they are powerless. From that simple acknowledgment, if embraced by the client, recovery can begin.

The key to recovery, according to Mr. Callahan, goes like this: "Walking one step at a time in the direction you want to go when every bit of you wants to sit down and quit.  We need to guide our clients toward the wisdom of recovery by asking HOW, which stands for honesty, openness and willingness." 

Addiction recovery is a strategy of baby steps, breaking a single day down to an hour, or a minute, at a time. 

Healthcare providers, nurses, counselors and case managers must be alert to opportunities that capture the moment, that identify a subtle inquisitive spark of interest and then implement an opportunistic intervention. "Easy does it," – a calming comment made by the team every day to anxious fragile clients. “Just give it five more minutes,” was a bargaining approach one Detox nurse used.  Then five more minutes, and then an hour, and then a day.

Mr. Callahan continues, "Every moment of every day the recovering person is faced with choices that will either support recovery or not. If they choose the behavior that supports recovery often enough, it can become a new and healthy way of life." 

It takes a very special group of healthcare professionals who are constantly alert to an opportunity to break through the wall of indifference, anger and hostility. Few are willing to step into the addict’s shoes and look at the world from their perspective. The “make a difference” opportunities are often subtle―a tear, a nod, a comment in passing – that create an intervention moment. 

In the blink of an eye, the journey out of addiction and hopelessness can mark the rebirth of a life and a new beginning.

Resources:

www.samhsa.gov/newsroom/advisories
www.samhsa.gov
www.nursingspectrum.com – “Coming Soon to Your Neighborhood: Meth Abuse”; Judith Sutherland, RN, MN, PhD
http://troubledwith.com/stellent/groups/public - “Alcoholism - Addiction Triggers;” Archibald Hart, PhD
Case Management for Substance Abuse Treatment: A Guide for Treatment Providers (Based on Treatment Improvement Protocol – TIP_ 27; US Department of Health and Human Services, available on www.samhsa.gov
www.AA.org
Cove Forge Detox Team - the expert addictions nursing and counselor staff of Cove Forge/White Deer Run
The Big Book

The authors wish to thank all the nurses, technicians, medical staff and administration who have worked together to help others reach for the stars. Thank you!

Authors:
Cathy Kauffman-Nearhoof is a Certified Case Manager, Managed Care Nurse and Legal Nurse Consultant.  She is the Nursing Director for Cove Forge Behavioral Health. 800-873-2131 or cnearhoof@crchealth.com
Kelly Steele, BSN, RN is the Unit Coordinator for the Detox Unit at Cove Forge.  800-873-2131 or at ksteele@crchealth.com
Liz Ruhlman, BA, CCDP is the Detox Counselor/Case Manager for the Detox Unit at Cove Forge.  814-873-2131 or at lruhlman@crchealth.com