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A continuing-care mindset

December 1, 2007
by A. KENISON ROY, MD, FASAM
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A Louisiana program builds flexibility into its continuum of treatment

The American Society of Addiction Medicine (ASAM) defines alcoholism as a chronic and progressive disease characterized by continuous or periodic impaired control over drinking, preoccupation with alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial. We all know that patients can and do benefit greatly from treatment, but the rate of relapse is high. We deal with a disease that affects our patients for a lifetime. At Addiction Recovery Resources of New Orleans (ARRNO), we believe that treatment should acknowledge that reality, recognizing relapse as an indication for a revisit of the treatment plan, not discharge.

At ARRNO, we have left behind the cookie-cutter approach to the treatment of addiction. Our program is based on the disease of addiction as a chronic illness, similar to other chronic illnesses that require individualized care. We have established protocols to move patients through a continuum of levels of care and intensities of service to meet individual needs. Our philosophy is intentionally similar to that of any other chronic disease management model, such as one governing treatment for asthma or hypertension.

ARRNO began in 1992 as an effort of the Young Leadership Council, a philanthropic association in New Orleans. The program originally was based on a 90-day residential treatment model prominent at that time (Metro Atlanta Recovery Residences). An early board member had experience with that facility and gave rise to the idea of bringing this type of treatment to the New Orleans area.

Flexible services

Over time and with the evolution of medical treatment for addiction, the facility and its treatment programs have evolved as well. Length of stay in our residential program varies based on the individual's needs. Our intensive outpatient treatment program includes a residential component for those people whose appropriate level of care is outpatient but who do not have supportive living arrangements.

We can detoxify patients in either an ambulatory or residential setting. We can and frequently do address psychiatric comorbidity (such as bipolar disorder, unipolar depression, attention-deficit disorder, and personality disorders) with medication and with specialized behavioral and psychotherapeutic techniques.

Our IOP constitutes the usual referral for patients with “a house, a spouse, and a job,” or for those not previously in treatment. We conduct this program in the evening and encourage patients to continue in the workplace when detoxification issues resolve. A unique understanding is that couples should be in treatment together, as they usually have different but complimentary aspects of addictive disorder. There is no additional charge for the presence of the spouse. Sometimes in these arrangements individuals present to group alone or are separated from their significant other to work on sensitive issues, but rarely is this necessary. Patients who fail IOP by repeated relapse or who have had previous treatment and then relapsed are referred to our residential treatment program.

Residential treatment is set up with an initial education phase. This includes groups and lectures throughout the day, exercise and recreational participation, attention to activities of daily living in a community setting, and 12-Step attendance in the evening. Residents live four to six people in three-bedroom apartments segregated by gender. Men and women often live in adjacent apartments.

The interpersonal relational aspects of this community are seen as a key element of the treatment process, as is the cooperative engagement in household chores. Interaction among patients with unhealthy relationship skills is an important part of the community component of treatment and is often an opening into the need for change at depth. Often, opposite gender attraction issues emerge, and these are part of the community milieu therapy. (Of course, our “Cardinal Rules” prohibit sexual acting-out.)


There is a strong 12-Step orientation, with daily 12-Step attendance facilitated and required. Transportation is provided for a variety of 12-Step meetings, so that patients are exposed to groups with which they can identify.

Following completion of the education phase in residential treatment, patients transition to the application phase. The idea here is that vocational considerations are crucial to recovery. Patients are required to return to their current employment, find employment if they don't have a job, enter school, or, in the case of the occasional retired or disabled person, engage in volunteer work. A foundation belief is that good recovery requires participation in society and that participation in society promotes good recovery.

The various activities of the community continue during the application phase. A number of people return to their homes at this stage. Groups meet in the evening and address issues that are frequent components of relapse. The psychotherapy group is primarily interpersonal but borrows heavily from treatment programs for adult children of alcoholics and other types of dysfunctional families. The focus is on identifying and appropriately processing feelings and healing developmental trauma while learning skills of self-parenting. Originally we aimed to make this a two-month process, but over time the range of continued participation in the application phase has become one to 12 months.

Our continuing care is a lengthier process following IOP or completion of the application phase of residential treatment, and is unique in that there is an out-of-pocket expense involved ($20). Groups are kept small and focus on treatment plan goals and objectives. The therapists are master's-prepared and have ongoing professional relationships with their patients.

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