What happens when a sober patient comes in and says, “I’m not certain if I need treatment or not”? This is a seldom seen phase of addiction care, when a sober “long-timer” comes to therapy in order to work on issues.
It is not about denial. The clinical focus here may not even be about “BUDD” (Building Up to a Drink or Drug). Looking more deeply to Terence Gorski's relapse work(1) or to a 2000 study cited by the National Institute on Drug Abuse (NIDA) about chronic disease relapse rates(2) might be helpful in order to rule out those concerns, because this is not always about relapse. And while this might sound very similar to what “high-functioning alcoholics”(3) would wonder about, those individuals are so new in their sobriety efforts that the difference is obvious.
Rather, these are the long-timers who have “walked the walk” in the program after two decades or more, and yet seem to recognize that something is clinically off just a little bit for them.
This is a difficult phase to diagnose and treat correctly in addiction care. I believe there are some subtle factors related to the chronic nature of addiction and the long-term aspects of wellness to be considered here. I believe this “questioning phase” in long-term sobriety represents a stage of recovery, and I don’t find much written about it. People with long-term sobriety (going on 15, 20, 30 or more years of good total abstinence with a deep connection to the 12 Steps, the fellowship, and a spiritual program) are now showing up regularly in my private practice.
The correct DSM diagnostic assessment has been tricky here (because of the acute nature of the diagnosis), and thus it might be helpful to look at anxiety or depression in these cases, for sometimes those diagnoses might fit for insurance billing purposes. But that does not directly address the chronic disease aspect emerging from the whole addiction recovery issue seen here. Labeling it an existential issue might be technically correct, but it really doesn’t help the patient in working through the issue by giving it a fancy name. Sometimes, adjustment disorder offers the closest diagnosis, but over time I have seen enough people now to wonder if there is another later phase of sobriety that has not been previously discussed in the literature.
This is a particular stage that I wish would be further explored and professionally documented. Yet as Omar Manejwala, MD, points out(4), it is very difficult to find many of these long-timer patients to study, much less to locate the money to conduct proper research.
The stories I hear from patients in this phase have a common theme. It seems that these patients have lost the feeling of connection with other sober people, or believe they may have outgrown the program. They attend meetings—not as many as when they started—and find that they are one of the participants with the longest-running sobriety. They notice how the program has changed since they came in way back when, but they can’t share this with others very easily.
These long-timers are the people who say something in a meeting sometimes, and also are very connected to other long-timers but say there just aren’t too many of them around. These are the people who led many meetings over the years, but now are a lot more quiet in order to give the newcomers time to talk. These participants, who have a thorough knowledge of recovery material, don’t offer too much unless asked, because “it was different back when I got sober.” And so these are the people who sometimes are heard to grumble about others, “They just don’t know what they are talking about yet, because they are too new.”
Patients are coming to therapy reporting that they are working their program and yet are feeling that something is off. The presentation takes a form of sober loneliness, with a style of grief, subtle irritability, and doubt. There are so few other long-timers with whom they can relate that it may be difficult for them to speak with anyone else about this condition. The long-timers receive a lot of ego boosting, or a lot of silence, neither of which may be good for their sobriety. Things have changed in their lives, and yet their sobriety efforts may not have kept pace.
The long-timers may have such strong opinions and ways of acting over a couple of decades in sobriety that they are not always as open, humble or accepting of genuine sharing and learning as they were when they were a newcomer.
When I sit with these patients, I quickly refer to John Hart’s newspaper comic strip “B.C.”, in which the wise guru from the Stone Age sat on the peak of one mountain and needed something. The guru then got up and off the mountain peak to make the long descent down the mountain, across the endless valley, and over to the other mountain range far away, in order to climb up another mountain to ask something of the other guru sitting on that peak. This is commonly understood by each of the long-timers in this stage of care.
My clinical focus is to normalize this as a stage of healthy sobriety, because so many long-timers are afraid that what they are feeling is a precursor to a relapse.
We do a thorough clinical assessment to determine if there are any underlying issues. I direct them to return more frequently to 12-Step meetings, because they have not gone to as many over the past years as they felt no need—there was no urge to drink or have the old chaos return.
I ask them to monitor their participation in the meetings, both in feeling their feelings and watching their actions. I encourage them not just to sit there, but to participate more. Next, I review their recent work on the first three Steps, and take time in treatment to explore in depth what they are doing in these Steps.