Behavioral Modification Program
Key Psychological Strategies.
Successful recovery programs leverage key behavioral conditioning approaches that promote abstinence-induced neuroplastic change in the brain. These approaches lead to the extinguishment of craving and the development of a new belief system that sustains long-term remission from substance use disorder (SUD). The addict, once free of the dysfunctional behaviors characterized by active use SUD, can effectively clear the wreckage caused by addiction and go on to live a productive and fulfilled life. Continual, life-long maintenance is often essential to maintaining long-term SUD remission.
Operant Conditioning
Operant conditioning is a method of behavioral change that occurs through learning, reinforced by the administration of rewards and punishments for behavior. In the context of SUD, the operant conditioning paradigm consists of: 1) external reinforcement of abstinence through loss aversion protocols together with; 2) the simultaneous development of healthy behavioral choice objectives reinforced through experiencing the repeated positive rewards of remaining abstinent. Punishment reinforcers are effective at starting the change process, but to sustain long-term, stable change the motivational source must shift and become internally driven.
SUD dwells in the dopaminergic neural pathway of the brain. Dopamine is the critical neurotransmitter in many aspects of mood, motivation, learning, memory, focus, energy, and the ability to experience pleasure in pursuing healthy and naturally rewarding behavioral objectives. As addiction develops over time, the dopamine pathways of the brain are hijacked. Motivation to engage in healthy behaviors is replaced by an ever-increasing, all-consuming pursuit of drug-induced rewards. Operant conditioning techniques establish new, healthy dopaminergic chemistry in the brain leading to abstinent behavioral choices over time.
Power of the Peer.
Another psychological construct plays an important role in recovery - The power of the peer. Peer power is a form of operant conditioning. We humans are profoundly social beings. We crave the acceptance and approval of our peers and our important social connections. We are averse to disappointing people and losing connections. Humans have to operate within the bounds of social expectation or face ostracization, which threatens survival. Peer power is a very strong motivator for change.
Recovery communities are exceptionally beneficial in establishing and reinforcing the development of new, abstinent belief systems. But addicts in early recovery are almost uniformly reticent to fully engage in peer support at the outset. Addicts tend to run on self-will, and often are untrusting. Building these new healthy bonds, and adopting beneficial modeling behavior takes time. Ensuring meeting attendance in early recovery is critical. There is an old adage - "All of us hated AA at first, then after a while, we started to crave seeing our sober friends at meetings instead of craving alcohol and isolation." Our peers in recovery are invaluable in instilling and sustaining our new belief systems that allow us to remain sober, recover, and grow.
Our professional peers are also critical in the recovery process. We want to remain sober. We want to keep our jobs and careers. We want to keep our families, and be productive and worthy people. But the pull of the addicted brain is inexplicably powerful, especially in early recovery where the brain is cementing neuroplastic change. If the addicted brain in early recovery sees a way to use and get away with it, it most likely will use. Such is the power of craving. When the addicted brain knows that it is being monitored, and any use will be detected, craving diminishes dramatically. Craving is a function of expectation - The expectation of the euphoria of use, and the expectation that others, who hold the keys to something we desperately don't want to lose, won't find out about the use. Knowing that we will be caught and lose a job, a law license, or something else we value, is an exceptionally powerful peer incentive that reduces temporal craving urges, allowing for sufficient time for abstinence induced brain change to eliminate craving.
The power of the peer is one of the most powerful tools in the arsenal of recovery. Monitoring both abstinence and aftercare compliance has been categorically proven to effectively maximize the power of the peer to aid those in the early stages of recovery.
Altering the Delay-Discounting Dysfunction.
One of the primary objectives of employing operant conditioning and the power of the peer in SUD recovery is to right the dysfunctional delay-discounting paradigm characteristic of addiction. Delay-discounting is a psychological phenomenon where a person will choose a smaller, immediate reward at the expense of larger delayed rewards. Impulsive people tend to exhibit delay-discounting dysfunction by embracing immediate rewards to the exclusion of later, larger rewards. Impulsivity is a behavioral attribute with strong expression in those afflicted with SUD.
People in active addiction operate in a steep delay-discounting behavioral zone. Addicts have a very distorted sense of time as it relates to healthy behaviors. The drive of addiction forces the brain to focus on the immediate in the form of using. This phenomenon of compulsive hyper-focus on the "right now" disrupts the addict's ability to engage in long-term planning, goal setting, and integration of higher-ordered executive functioning to direct sustained effort toward behaviors that promote the achievement of healthy, longer-term objectives.
Those who have progressed to severe SUD begin to engage in impulsive, desperate behavior to sate the compulsively uncontrollable craving to use. Crime, prostitution, violence, and other moral aberrations, that the individual would never engage in but for SUD, become necessary to use. By this point, using is required for the addict to function, both biologically and psychologically. In later stage SUD, use and survival equate to the same thing in the brain of an addict.
SUD is a progressive disorder. In the vast majority of those with more severe SUD, continued progression will lead to escalating levels of unacceptable behavior. There is an old AA adage that has proven true, time and time again: "Addiction leads to three places - Jails, institutions, and death." A "high-functioning" alcoholic or addict, like most afflicted legal professionals, can use for years without serious consequences, but then very quickly go from relative stability to engaging in use-driven behaviors that jeopardize life and liberty. Interrupting the dysfunctional delay-discounting syndrome is critical to arresting the progression of SUD.
Effective monitoring is the most efficacious way to disrupt the dysfunctional delay discounting perception of the addicted brain. The certainty of getting caught, and concomitant loss of job or career, act in concert as a highly effective deterrents to prevent use. Enforcing aftercare participation acts to instill and foster an abstinent belief system that leads to successful, long-term remission.
The Protocols
The Vivon system consists of protocols that maximize operant conditioning as a behavioral change agent to minimize and eventually extinguish craving. These protocols also create a new, healthy cognitive construct that promotes normalization of the delay-discounting paradigm, leading to a higher-ordered, abstinent belief system and the re-establishment of healthy behavioral constructs. The elements of the Vivon protocol are:
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Initial Treatment Assessment
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Referral to Appropriate Treatment Provider
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Family and Social Group Education
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Employer Liaison
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Biological Monitoring
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Recovery Support Groups - AA, NA, etc.
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Recovery Support Compliance Monitoring
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Regular Check-ins
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Physical Health Plan
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24 Hour Geolocation and Geofencing Monitoring
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Weekly Report Card.
Initial Treatment Assessment
The need for a treatment assessment is usually sparked by a precipitating crisis event (PCE). A PCE is use related behavior that is so aberrant or unacceptable that one or more of the stakeholders in the addicted legal professional's life (family, employer, colleague, or friend), becomes motivated to take definitive action.
This is a critical step. Lawyers are difficult to talk into treatment. An intervention with a professional knowledgable about SUD and the practice of law, and/or peer volunteers with the local lawyer's assistance program (LAP) is usually the best approach. At this stage, the legal employer should consult with a specialist. The legal employer also has ethical duties mandated by the rules of professional conduct to ensure that the afflicted attorney is not practicing while impaired. The legal employer needs to review and consider these ethical obligations.
Once the lawyer agrees to seek help, the next step is to find an appropriate treatment venue. An intensive outpatient program (IOP) may be appropriate depending on the severity of the SUD, or inpatient may be necessary. A professional assessment is usually required to determine the suitable level of care.
The choice of a treatment facility is important. There are over 14,500 treatment facilities in the US. Not all are created equally. If inpatient treatment is indicated, it is always preferential to use one of the few programs in the country designed for legal professionals. If that isn't possible, the program should meet certain criteria. The facility should have a strong family program. It should have acute detox capability if required. It should provide psychiatric and psychological assessments as part of the treatment process to identify any co-occurring mental health issues.
Vivon has vetted both inpatient and IOP treatment facilities across the nation. We are happy to assist with the choice of either an inpatient or outpatient facility.
It is extremely advantageous for an attorney entering treatment for the first time to be prepared. Someone, preferably another legal professional who has gone through formal treatment should explain the process, and provide an overview of what to expect. It has been shown that people who are prepared before entering treatment are more apt to embrace the process and have better outcomes.
Family Recovery - Social Group Education
Addiction is very much a family disease. It creates dysfunctional dynamics within families that need to be addressed to promote familial behaviors that will foster the family's recovery, and support the addict's sustained remission. It is highly recommended that the afflicted attorney attend a treatment program that provides a robust family program. Family members are also strongly encouraged to explore and attend Al-Anon and Al-Ateen support groups.
The lawyer's important social contacts should also be educated to ensure they understand the requirement for abstinence and the ways they can be supportive. In our experience as recovering addicts, we've found that many of our drinking buddies became our greatest supporters in recovery, but its not uncommon for friends to lack the knowledge of how to appropriately interface with a friend in recovery.
Legal Employer Liaison
This piece of the protocol is frequently the lynchpin to an attorney's successful recovery and is often the component that requires the most nuance. The reality is that addicts will jettison almost everything of value in their lives to continue to use. The one exception is the job. The job is almost always thing the last to go. The prospect of job loss always gives the addict reason to pause and consider getting sober. It's not always easy with lawyers, because many have options to change jobs, but with the proper approach, and the appropriate emphasis on the rules of professional conduct, the employer becomes a vital component in motivating and sustaining the behavioral change required to achieve long-term remission.
Unfortunately, the vast majority of legal employers are wholly undereducated on the topic of SUD. Vivon provides that education and the protocols that best motivate a lawyer who needs help. Our programs effectively utilize employer leverage to support the afflicted attorney in the critical early phase of recovery.
The employer must appoint an individual attorney to act as the reporting authority. Vivon will provide reports to HR departments as well, but it is vital that an attorney within the organization be the point contact. This person receives the reports Vivon generates throughout the aftercare protocol. The report attorney doesn't have much work to do, other than receive reports, and interface with Vivon if an issue arises. The choice of this person is important. The reporting authority should have a influence with the afflicted attorney, and a relatively close relationship. This attorney should also have an authoritative presence within the organization, and should be someone who the recovering attorney will go to great lengths not to disappoint.
This component of the protocol is one of the most important vehicles for invoking the loss-aversion dynamic. When a person in early recovery knows that he or she is being constantly monitored, and knows that any resumption of use will be immediately reported to the reporting authority, the drive to compulsively succumb to temporal craving episodes is greatly diminished. The power of the peer is also invoked. The recovering attorney is far more likely to comply with all aspects of aftercare when a person he knows, trusts, and respects is regularly reviewing aftercare compliance.
Biological Monitoring.
Our Biological monitoring program makes it virtually impossible to use any psychoactive drug and escape detection. The combination of the Sobereye system with our hair follicle testing regime creates the expectation that use will be detected. This dynamic reduces craving, making it easier for the afflicted attorney to resist impulses to resume use. Biological monitoring leverages the power of loss-aversion and the power of the peer to disrupt continued use, promoting the neuroplastic brain change that leads to diminished craving and the eventual establishment of long-term remission.
Recovery Support Groups - AA and NA
Alcoholics Anonymous, Narcotics Anonymous and other 12 step recovery groups are extremely effective, especially in early recovery. The great advantage of AA is it's ubiquity, AA is present in virtually all communities across the country. AA is free, although a donation of a couple of dollars per meeting is customary. Meetings are held at times that accommodate work schedules. The power of the peer fostered by AA, especially when those peers are also in recovery, is a powerful antidote to relapse.
Isolation is a hallmark of addiction and a driver of relapse. Recovery communities combat the intense feelings of isolation that predominant in early recovery. The newly recovering addict finds love, support, empathy and a safe haven to begin the process of learning to live anew as a sober person. Participation in AA has been shown to alter neural pathways over time, creating biochemical changes in the brain that not only support the extinguishment of craving, but also the establishment of healthy and productive behaviors, and new belief systems.
Belonging to a recovery support community is one of the most important components of successful recovery. AA has been proven to be effective. (See 2020 Study). See the study authors discuss their findings on the efficacy of AA in the video below.
It does take time to build bonds in recovery support groups. At Vivon, we adhere to the recommendations that nearly all treatment centers provide at discharge. Our clients are required to attend 90 AA meetings in 90 days after discharge. We also require that our clients find a sponsor, and get a service position at an AA home group. Frequent meeting attendance, sponsorship and service build critical bonds far more quickly, which helps to stabilize those in early recovery (Learn more about AA).
Vivon support personnel are all active members of AA, and we work with our clients to integrate them into the AA family. We also find local lawyers in AA to assist the newly recovering attorney entering the program. Early recovery is difficult, our bodies and brains are adjusting and changing. Dopaminergic neural pathways in the brain remain disrupted for several months into sobriety, which causes discomfort and emotional upset. Having caring people, who have "been there" and know just how you're feeling is invaluable support in getting through the early recovery period.
While nobody grows up wishing to become a member of Alcoholics Anonymous, those who have spent the time and effort to belong and contribute have found it to be one the greatest gifts of recovery. Where we used to crave intoxication and isolation, we now crave to attend meetings and help others. AA participation truly does reshape the brain, promoting healthy cognition, social connection and emotional stability. It gives those of us in recovery a sense of healthy serenity, that we take into the greater world.
Recovery Support Compliance Monitoring
While AA is wonderful, it is an exceptionally strange experience for those new to the program. For most it is a new paradigm that is unfamiliar and uncomfortable at first. Virtually everyone who has any time in AA will attest to hating it at first. It takes time to appreciate the life saving attributes the program provides. AA also takes effort and time away from other activities, so there is motivation to skip meetings or not attend as frequently as one should, or one would like to go.
The smart phone recovery platforms that Vivon utilizes has geolocation features that allow verification of AA meeting attendance. This is an important accountability component of early recovery. The traditional way that courts, and other institutions use to confirm attendance is to have the AA meeting chairperson sign attendance verification slips. For whatever reason, having to present a slip for signature is the one thing that AA newcomers dread. It drives many away, and causes many others to become "slip forgers." Our system eliminates the stigma of having to present slips, and provides a far more effective means of ensuring attendance.
Regular Check-ins
Vivon assigns a staff member to each of our clients. Assigned staff members monitor recovery. They monitor Sobereye abstinence checks, geolocation data, smart phone app data, AA meeting attendance, and other recovery related items prescribed by treatment providers. Our staff members are intimately knowledgable about their assignees' recovery progress. Staff have video conferences or talk on the phone with their assigned client at regular intervals.
Support check-ins allow Vivon to determine whether there are any particular issues that the client is struggling with that need to be addressed, or referred to a treatment provider. Check-ins also allow us to determine if there are any work related issues that the employer should be aware of to ensure appropriate support. Regular, supportive, peer check-ins have been shown to dramatically lower relapse potential.
Physical Health Plan
Unless our clients have a medical limitation, we want them to engage in a physical health plan. Addiction ravages not only the brain, but also the body. New research shows that exercise and proper nutrition are not only advantageous for the body, but they are even more beneficial for developing a healthy brain.
Exercise increases the volume of the hippocampus, the area of the mid-brain where memory is formed and stored. It promotes mental focus, clarity, cognition and naturally increases energy levels. Exercise greatly aids in regulating hormones and neurotransmitters that are out of balance in early recovery. It naturally increases endorphins in the brain that help ease the feelings of discomfort caused by depleted dopamine levels during early remission. There are an incredible array of benefits, to numerable to list here, that exercise provides to everyone, especially to those that are newly sober.
We want our clients to utilize exercise programs that are community centric. Programs that have regular classes that are group oriented where bonds are built, and connections made. Organizations like Curves, CrossFit, F-45 and the like provide people in recovery with exposure to a new health centric environment. A community based exercise dynamic promotes the development of healthy habits in all facets of life. Becoming physically healthy, greatly aids in becoming emotionally and cognitively healthy.
Gym time also effectively replaces bar time. For most with an alcohol problem, spending an inordinate amount of time in bars is a deeply habituated behavior. The "pull of the bar" is very powerful in early recovery. Establishing a regular, community based exercise regime quickly becomes habit forming. An exercise protocol effectively substitutes a healthy physical location as a replacement for the high relapse risk environment of a bar. Chin-ups on an exercise bar are far better than the a chin down on a liquor bar.
Geolocation and Geofencing
One of the most powerful features of smart phone technology is the recent development of geolocation and geofencing capability. Vivon uses a platform that allows us to monitor the location of our clients at all times. Geofencing is the marking of particular high risk environments - Bars, restaurants, grocery stores, gas stations, convenience stores, areas known for drug dealing, etc. When a client enters a high risk zone, Vivon is alerted. We follow-up with our clients to ensure that a valid reason exists for the client to be in a high-risk zone.
This piece may seem like overkill, but it is vitally important in the early phase of recovery. Location accountability effectively shuts down the "auto-pilot addict." Nearly all of who have had a severe active use SUD problem have experienced the "auto-pilot addict" phenomenon. It is deeply rooted in the subconscious cue, trigger, craving use paradigm of addiction. We can be fine one minute and as we're driving along past the 7-11, the auto-pilot alcoholic appears out of nowhere. Without being fully conscious of our choice, we pull in to the store and we're drunk again.
When a person in early recovery knows that his location is being constantly monitored, cravings are greatly diminished, and accountability is significantly enhanced. The expectation of being caught immediately is a powerful impediment to using.
We require that our clients in early recovery have their smart phones with them at all times. We send out periodic alerts, requiring iris recognition verification to ensure that the client and her phone are in the same location. It takes just a few seconds to respond to the alerts, and only requires that the client look at the phone.
Geolocation and geofencing also allow us to ensure that clients are attending support meetings and participating in their other location specific recovery activities. We work with our clients specific schedules to allow for flexibility while also ensuring biological verification and recovery program compliance.
Weekly Report Card
Vivon generates weekly "report cards." The report card is distributed to the reporting authority designated by the employer. Others can be added to the recipient list.
The report card is a very effective feed-back reinforcer. This strategy works extremely well as a behavioral change motivator for those in recovery, like lawyers, who have strived since childhood to achieve high academic success. This motivational construct draws on life-long, deeply embedded declarative belief systems formed during childhood, prior to onset of SUD.
Report cards invoke the power of the peer, and create a feedback loop that increases awareness in the newly recovering attorney to areas where requirements are being met, and where more effort and focus are needed. Getting A's becomes a priority, and those who get A's have excellent odds of achieving long-term remission.
Our clients are graded on 8 different "subjects."
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Support group meeting attendance
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Progress toward life problems resolution
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Physical health plan compliance
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Abstinence monitoring compliance
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Compliance with any co-occurring mental health treatment protocols
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Progress toward goals desired by the client
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Smart phone app engagement and location tracking compliance.
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Abstinence
Clients are graded on A-F scale in each "subject", with a cumulative "GPA" reported every week.
The report card is a highly effective tool. Throughout our adult lives, we remain strongly attached to the motivators developed during childhood that created our beliefs about ourselves - Declarative beliefs like: "I get good grades. I am an excellent student. I have always strived to show my teachers and professors that I am succeeding." Our semi-conscious, declarative identity is one of the strongest drivers of behavior. Addiction disrupts our fundamental declarative belief system. Utilizing early childhood motivators is akin to going home to our early, healthy belief constructs. Craving good grades supplants the craving for intoxication and isolation.
Time
Time is such a critical concept in early recovery. Addicts live in the right now. The horizon to a healthy life is exceptionally difficult to see in the first months of abstinence. Employers and others close to addict also have a distorted relationship with time as it pertains to addiction. Everybody wants it fixed, right now, with as little disruption as possible. There is a misconception that 28 days should fix everything. It doesn't, it's just the beginning. Without an aftercare program and compliance monitoring, active use almost always keeps cycling, which exhausts the addict, and those close to the addict.
One of the most common questions we receive is "how long does it take to get my brain back?" In our personal recovery journeys we came to understand that we didn't want our old brain's back. We needed to develop new perspectives and belief systems that would not only extinguish craving but more importantly, foster a greater awareness of our emotional selves. We needed new, emotionally aware brains.
So how long to get a new, healthy, emotionally aware brain? It happens imperceptibly, every day. The paradox of early recovery is that we get markedly healthier every day, while feeling worse in the first few months of recovery. Our bodies and brains are readjusting to a healthy physical homeostasis. Addiction creates an imbalance of neurotransmitters and hormones in the brain and body that take time to normalize and become healthy.
How long does it take to get stabilized?
Everyone is different, but some general patterns exist. We know the first few months are critical. The brain and the body are rapidly reestablishing physiological homeostasis. This process is painful and filled with craving episodes. The more time one gets, the more cravings diminish, and the greater the change to a healthy balance of neurotransmitters and hormones. Over time, as these changes cement and healthy coping paradigms are strengthened, the addict becomes more stable. Its a gradual process. Recovery should be a top priority in the first year of abstinence. Generally, people who are properly supported can punch through the portal and become stabilized within the first couple of years of recovery if they do the work and remain abstinent.
Effective monitoring and community support are vital to reaching stable recovery. The vast majority who are effectively monitored and engaged in a recovery program do not relapse and reach long-term remission. Those who aren't monitored and extrinsically motivated to remain engaged in early recovery, typically remain stuck in the cycle of active use for years, until they either destroy everything in their lives and hit rock bottom, or die.