Bradley F. Sorte, MSW, MBA
Chief Revenue Officer and EVP of Regional Continuum
Ryan Hanson, MA, CAP
Executive Director of Caron Renaissance
“I remembered when I went to start Renaissance that the first rule of medicine is ‘doctor do no harm’, so I started thinking about ‘doctor do no harm,’ and how that would apply in a chemical dependency setting. The way I saw it was: do not enable.” -- Sid Goodman, Founder of Caron Renaissance.
It is the mission of Caron Renaissance to reverse the multi-systemic process of substance use disorders and other disorders along the obsessive-compulsive spectrum. Clinical interventions are driven by a positive belief in personal change, which we believe is best accomplished in an environment that challenges self-deception, is non-enabling, and supports conscious progress directed toward a mutual win-win of social interdependence.
Nearly 30 years ago Sid Goodman founded The Renaissance Institute of Palm Beach in response to individuals leaving residential treatment centers unprepared for sobriety in the real world. Unsurprisingly, they returned to active use and ultimately, if they were lucky, back to treatment.
This dynamic inspired Goodman to develop the clinical program for Renaissance based on a long-term, clinically intensive model built around the Renaissance clinical philosophy. That philosophy, The Psychodynamic Approach to Treatment: The Biopsychosocial Model Revisited, guided the development of the Renaissance Model. In that model, patients live in a separate location from the facility where clinical services are delivered. The reasoning behind that separation was to create an environment where people can practice a life in sobriety before they return to their lives outside the treatment center doors.
The concept is similar to medical practice for injuries. Think about someone who has knee replacement surgery, for example. They aren’t thrown out of the hospital once they recover from the surgery and left to figure out the rest on their own. Instead, as they recover, they also begin physical therapy as soon as possible to rehabilitate the muscles and begin to return to normal function. In much the same way, Goodman wanted patients to use their time in treatment “rehabilitating” the muscles necessary for sobriety.
The Renaissance Model allows patients to leave treatment stronger, more prepared, and having likely already regressed and worked through many of the pitfalls they would have had to deal with first at home under more traditional models.
While we have seen many evolutions in the practice of working with people who have substance use disorders and compulsive behaviors over the past 30 years, Goodman’s clinical philosophy and its complementary document, Road Map to Recovery, continue to provide the backbone of what we do at Caron Renaissance.
This new document — our approach to treatment — builds on that legacy and elaborates on the progress that has occurred in the past decades to create a clear picture of who we are, what we do, why we do it, and, most important, how it works.
Our recommendation is that you begin with this document to gain a full understanding of our program and then read both the clinical philosophy and the road map document in that order. They help to provide additional details and a clinical framework for our program. In particular, they cover how the Renaissance Model was developed and works, personality development and its role in recovery, and the role of dependence and goal of interdependence in active use and recovery. While it is a lot of information, the two documents illuminate the components of what we do and why they are important to lasting recovery. We consider them the first step in the education that you and your family need as we begin our work together.
Ultimately, we believe you will see the Caron Renaissance model as a unique and highly specialized approach that goes far beyond treating substance use disorders and compulsive behaviors. When fully embraced, this approach will provide a launchpad for you and your family into a life of recovery and potential that is elusive for far too many.
Thank you for your time and trust in us to help you and your family in what is likely one of the most important decisions of your lives. We look forward working together with you.
Bradley F. Sorte, MSW, MBA
Executive Vice President & Managing Director of the Florida Continuum
Caron Treatment Centers
Substance use disorders and other compulsive behavior disorders are complex and interact with people on multiple levels: mental, physical, emotional, and spiritual. Focusing on the addiction alone will not result in stable and long-lasting mental health and the ability to create and maintain a healthy life. To ensure the fullest and longest-lasting recovery, treatment requires a comprehensive focus on all of those levels. Just as addiction does not define who the patient is as a whole individual, we cannot focus on treating the addiction by itself if we want to assist patients in creating a healthy and productive life in recovery. That’s why we treat people from a biopsychosocial standpoint.
Treating Substance Use Disorder Prior to Addiction
This is a question we often hear from family members: I know my loved one has a problem with drugs and/or alcohol but I don’t think they have an addiction. Is this possible?
This is a common dilemma that many of our patients and their families are dealing with. We know that, according to the American Society of Addiction Medicine, addiction is a primary, chronic disease of brain reward, motivation, and related circuitry (ASAM, Vol 26, no.3 2011). We recognize, however, that not every person who is having problems with drugs and alcohol has developed an addiction. This does not mean that they cannot benefit from the help that we provide.
Just like a person who has developed cardiovascular disease would benefit from changes in diet, exercise, and nicotine cessation, a person who is at risk of developing an addiction can benefit from treatment that will hopefully prevent the onset of a chronic and fatal condition. Determining what treatment is needed and if an addiction is present undergoing a thorough assessment and targeted treatment planning to address the underlying issues that are driving the use of drugs and alcohol is required. If it is determined that an addiction is present, then treatment to treat that chronic health issue is also needed.
In summary, the answer to the question is that it is possible to have a substance use disorder and not yet have an addiction. Both situations require thorough assessment and rigorous treatment in order for the individual to get to a place of healthy functioning.
Four Clinical Lenses
Four clinical lenses make up our clinical philosophy, which guides our treatment model:
- Substance use/compulsive behaviors
- Underlying health and mental health issues
- Family systems
- Personality development/emotional maturity
Who We Treat
Our patients are:
- Adults and young adults: Most of our patients have not yet achieved the typical markers of the transition to successful adulthood (graduating college, leaving the family home, financial independence, entering the workforce, stable relationships, meaningful employment, etc.).
- People who have been in treatment multiple times: These previous treatment experiences suggest additional tools or modalities may be necessary. We review each case to ensure that a thorough assessment (ongoing through the course of treatment) and all necessary components are included.
- Families: Family members are as much our patients as the people with substance use disorder/compulsive behaviors. Our motto is: “The family is the patient, and the patient is the family.” We believe that family systems play a role in substance use and mental health. As we help families understand that they are not the cause of addiction, we also work with them to understand how each member may need to change in order to give the system the greatest chance of success. Through the work we do with families, they find ways to achieve healthy functioning and relationships.
Core Components of Caron Renaissance’s Treatment Programs
Long-term treatment: Caron Renaissance patients stay a minimum of three months and that minimum is extended as needed, based on each patient’s course of treatment. According to the National Institute on Drug Abuse1, research has shown that treatment lasting less than 90 days will have limited effectiveness while significantly longer treatment is recommended for maintaining positive outcomes. This is why:
- Brain functioning is affected by the substance used and length of time it was used. It takes time to regain healthy functioning after detox. The brain develops well- traveled “roads,” and it takes time and retraining for the brain to develop new pathways.2
- Treating the core issues takes time. Often, the mental health problems that gave rise to substance use and compulsive behaviors have taken decades to take hold. It takes time to accurately diagnose and treat them. We also emphasize family systems work—looking at and unraveling the family patterns and histories that have contributed to dysfunction and maladaptive coping mechanisms.
- Learning and using the new behaviors and skills that create the foundation of a healthy successful life post-treatment is a process and requires a protected environment. Those new skills encompass the practical ones needed to launch into autonomous living, including creating healthy relationships and setting and achieving educational and career goals.
Integrated medical expertise: Full-time, on-site physicians, psychiatrists, and other medical staff work alongside our addiction and mental health specialists to diagnose and treat patients through the use of treatments like medication-assisted treatment (MAT), neurofeedback, neuropsychiatric testing, psychiatric evaluations, pharmacogenomics, and psychopharmacology. (See page 11 for a list of therapies we use.) Their medical expertise and experience contributes to our ability to accurately diagnose and treat underlying mental health issues.
At Caron Renaissance, a thorough assessment is initiated at first encounter with all patients. This includes medical records from previous treatment episodes and providers, a current psychiatric evaluation, and a history and physical including laboratory studies. The assessment may also include neuropsychological/ neurocognitive screening (or targeted psychological, educational, or vocational test batteries when indicated), quantitative EEG brain mapping, pharmacogenomic testing, and evaluation for medication-assisted treatment. The information from the assessment is compiled and discussed with the treatment team and the patient, guiding the treatment plan forward.
In more complex cases where chronic relapsing, treatment failures, co-occurring disorders, and maladaptive characterological traits coincide, it is essential that the psychiatric, psychological, and brain circuitry abnormalities and neurotransmitter metabolizer states are identified, integrated, and cross validated during treatment to afford the patient the optimal climate for long-term recovery.
Spirituality: Caron’s approach to spiritual care is integration into patients’ treatment plans. Patients participate in spiritual activities each week, as well as having access to local spiritual leaders, faith communities, and the facilitation of 12 Step fellowships. Patients participate in a spiritual evaluation, and this information becomes a part of their medical record and can be referred to by every member of the treatment team. Needed action steps and/or interventions noted in the evaluation are incorporated into relevant goal areas in their written treatment plan. Thus, the team and patient are engaged collaboratively in spiritual work as an integrated part of treatment goals.
The spiritual counselor remains an engaged member of the patient’s treatment experience, giving lectures, leading and/or facilitating specialty groups and small groups, and providing individual consultations as needed.
Substance Use/Compulsive Behaviors
It is critical to understand that people suffering from substance use disorders/compulsive behaviors do not have to be initially willing to change in order for treatment to be effective3. In fact, most patients fall somewhere between mostly willing to change to overtly resistant. We work with the patient to create an objective case for change by giving them an understanding of:
- The consequences of not changing for their lives, career and educational goals, and relationships
- How their addiction and behavior affects those around them
People are not born addicted, but each of us is born with a specific predisposition to developing an addiction. That predisposition, combined with environmental factors and choices that we each make, either increases or decreases the likelihood of activating that predisposition. Frequently, individuals began to use substances to substitute for a variety of needs including attachment and belonging, relief from emotional or physical pain, and medicating underlying mental health issues. We refer to this type of use as “harmful use.”
When left unaddressed, harmful use that developed as a coping mechanism for underlying issues puts the individual at risk of developing an addiction to that substance or compulsive behavior, which may include:
- Digital addiction
Drug and alcohol use and compulsive behaviors are, in fact, part of the same suite of manifestations.
A key distinction here is that an individual who is in this high-risk, pre-addiction phase is largely driven by these underlying factors and that amelioration of these issues can lead to a greatly reduced reliance on substance use/compulsive behavior for self-regulation. Conversely, once a person has crossed the meridian into addiction, the disease of addiction takes on a state of functional autonomy. In other words, the individual has developed a primary, independent, and chronic illness that cannot be resolved simply by addressing the risk factors and predispositions that contributed to its creation.
To better understand functional autonomy and how it works, let’s look at diabetes, a common chronic illness. An individual who is suffering from diabetes is at risk for developing a variety of other illnesses and their risk of developing these conditions is influenced in part by factors such as lifestyle choices, medication compliance, etc. If the individual neglects their medication, exercise routine, and diet, they will be at an increased risk of developing complications. Gangrene, for example, may develop in their leg.
That gangrene is similar to addiction in that it is primary, independent, and will not be cured simply by treating the diabetes. It must have its own treatment plan, which will be most successful if carried out in conjunction with the treatment for diabetes so that the environment that allowed the infection to take hold in the first place is eliminated.
For some, substance use/compulsive behavior fills in for emotional comfort while for others it serves as a distraction from discomfort. Others gain a sense of control or use substances/compulsive behavior to avoid dealing with the discomfort. Maladaptive psychological defenses include:
- An inability to take control of their emotional life and take responsibility for their actions
- An inability to self soothe so they rely on outside gratification for comfort
- Belief in a life without consequences: they may understand what they should do but lack the ego strength to change their behavior
- An inability to define their core selves that results in self hatred, depression, and social withdrawal
A large part of the work we do at Caron Renaissance is focused on getting patients to look at the drivers of their behavior—traumas, messages, and/or sources of insecurity—in order to begin the process of recognizing what happened and to look at and deal with it in healthy ways.
Multiple Forms of Addiction
Change is difficult. As we move our patients to make core changes in themselves and their behavior, it is not surprising then that they will throw up defenses against those changes. Making unhealthy choices while in treatment is a marker for a set of problems the patient can’t deal with yet or isn’t even aware of yet. This is when other compulsive behaviors may emerge. These behaviors serve the same emotional needs: comfort or distraction from discomfort, avoidance, or control. Unhelpful behavior is the patient’s solution to problems they are not aware of yet or know about but don’t know how to deal with.
The emergence of those behaviors is a positive marker that treatment is working because it is getting close to something uncomfortable. The patient will regress in service of their ego, which is feeling threatened, and their desire to maintain the behaviors that have provided them with comfort/protection. The significance of these behaviors is often missed in less structured settings, which may result in less effective treatment.
Too often treatment focuses on the superficial behaviors as the primary issue without the depth and scope of investigation to see these behaviors as symptomatic. By getting past them, the door opens to address the real issues of insecurity, trauma, and mental health issues, among others.
For over 30 years, we have seen this pattern recur time after time. To help our patients manage the behavior, we have developed behavior-specific programming provided by staff trained to deal with that particular behavior, including gambling, shoplifting, hoarding, eating disorders, body image, digital addiction, anger, grief and loss, trauma, and sexual compulsivity issues. Interventions, support groups, and other types of therapies and treatments are coordinated for each patient’s particular situation.
When patients become aware of what they are doing and why, they are ready to learn healthier ways of coping. Our responsibility as the treatment team is to help them become aware of and learn healthy ways of coping with those issues. Ultimately by doing that, it helps to extinguish the set of behaviors they have been using because it’s all they have.
In 2017, the American College of Physicians4 joined other organizations and healthcare professionals in calling for substance use disorder to be managed as a chronic medical condition. As noted in a 2000 study, researchers have found that relapse rates for people with substance use disorders compares to those with type 2 diabetes, hypertension, and asthma.
We at Caron Renaissance also view substance use disorder and compulsive behaviors as a medical issue to be managed, rather than a moral failure. When someone relapses, it is an opportunity to re-assess their circumstances and needs, similar to the way a doctor would examine the circumstances and needs of someone with hypertension who experiences a second heart attack. Not all relapse is created equal. Accountability, boundaries, healthy communication, medication-assisted treatment, as well as the personal growth that the individual patient makes while in treatment are all possible protective factors that can have an immense impact on both decreasing the likelihood of a return to active use and increasing the likelihood that it will be less severe and the patient will return to remission in shorter order.
It is important that we do not define relapse in either/or terms: either using substances/compulsive behavior or not using. Relapse begins before actual use. In many cases, relapse begins as soon as an individual returns to a pattern of thinking and behavior consistent with their life in active use. Opportunities for the individual to regress in this framework happen daily in treatment and present valuable opportunities for intervention.
As noted in the graph above, for roughly half of individuals with a substance use disorder, sustained remission will not be possible and they will experience at least one episode of active use following treatment. For these patients, our first line of relapse treatment begins before it happens. As we integrate family, responsibilities, and sober expectations into the residential treatment experience, we allow for our patients to experience life in recovery in a structured environment. If regressions occur, we can deal with it immediately.
For those who relapse at later points in their recovery, we stress that reaching out for help is the right step to take. For families and friends, we recommend that they take the same approach: having an open attitude if relapse occurs and working with the individual to find treatment.
Our prescription for relapse is immediate intervention and treatment. When people relapse, we often find that they are facing a new set of challenges in some area, perhaps family systems work that still needs to be done or underlying mental health issues that have not been treated. Building on the foundation of previous treatment, we create a treatment regimen that moves patients back into remission/abstinence.
Our goal is to create the greatest likelihood of lifelong remission for our patients. For those for whom that lifelong remission is elusive, we work to provide the most responsive and available treatment continuum possible to help them return to a life in recovery.
Underlying Health and Mental Health Issues
Many of our patients do not have a specific personality disorder but rather exhibit traits of different personality disorders. Personality issues are tricky to work with because when someone has one, they feel that they are normal and everyone else has the problem. It’s usually the people around them who are acutely aware that something is wrong. We have to move from externalization of blame to the patient recognizing their role in what happens in their lives. Failure to mature past those unhealthy ways of viewing and dealing with the world stand as a tremendous barrier to long-term recovery.
These personality issues can lead to affective symptoms such as anxiety and depression that resolve when the patient reduces the dysfunctional thinking and behaviors. Treating the dysfunctional thinking and behaivors is a large part of creating fertile ground for someone to be in recovery. Leaving them untreated plays a role in addiction taking hold.
Caron Renaissance’s Approach to Personality Disorders
Our approach is similar to treatment of other medical conditions. In revisiting the knee surgery example: a patient has a knee that requires surgery. Her surgeon does the surgery, keeps her in the hospital to stabilize, and then sends her home. That is not the end of treatment, however. The surgeon will prescribe physical therapy, exercise, and other interventions for a period of weeks to months afterward. Similarly, we stabilize patients and then get them working on how to deal with the world outside our walls as soon as possible.
For the most part the personality issues we treat at Caron Renaissance are egosystonic, rather than egodystonic. That egosystonic state leads our patients to believe that the problems they experience are due not to their behavior but to others’ behavior. Our goal is to move them from that belief to being able to see their lives more objectively and identify their role in what happens to them rather than always looking for someone to blame. If they cannot move beyond those unhealthy views, their potential for success in the long term is limited. By using the psychological process of bringing the unconscious into the conscious, we are able to help people to see how their interactions may serve to perpetuate the challenges in relationships.
We can’t change someone’s fundamental personality style. What we can do, and have done with great success, is move our patients from a dysfunctional version of their personality styles to more socially, adaptable, and functional versions. For someone with traits of borderline personality disorder5 , for example, we provide them with tools to manage their emotions. Once they are able to do that, they can use their personality style to develop greater empathy and insightfulness. Those are qualities that are not only useful in everyday life and having successful relationships, they are also qualities that can lead to careers that require emotional intelligence and empathy.
A Messy Process
It’s an easy process to explain but the reality is messy. We are working with our patients to change how they view themselves, and that is often uncomfortable at best. Taking responsibility for their lives for the first time is a positive step but not an easy one. It’s especially hard for those who have had to radically shift their view of themselves and others as well as taking a deep dive into how they think and behave.
For those reasons, we recommend at least a three-month stay at Caron Renaissance. During that stay, patients typically move through several steps:
Step 1: Patients participate in a clinical philosophy group where they have a chance to examine personality development and look at the issues they struggle with and where they came from.
- What are those salient events from childhood and adolescence and how did the patient respond to them?
- How did those responses affect their emotional view of the world?
Step 2: Move patients into treatment that deals with emotional dysregulation caused by those issues.
- Dialectical behavioral therapy (DBT) is one of the most effective components of our clinical approach. It has been proven to help individuals dealing with personality issues<sup>6</sup> learn how to regulate their emotions in a healthier way so they don’t return to self-destructive behaviors or relapse.
- Employ a range of additional therapies as needed.
- Specialty treatment groups focus on specific issues, such as anger, adoption, parenting, eating disorders, gambling, shopping and spending, hoarding, sexual concerns, grief and loss, trauma and PTSD, body image, anxiety, and depression. We also provide gender-specific groups.
Step 3: Develop the tangible skills and coping mechanisms to deal with the challenges of managing emotions in a healthy way.
Step 4: Re-integrate family members into treatment.
- Teach family members how to respond differently. The patient with a personality disorder is not likely to be aware that something is wrong, but their family members are. They need to understand how to effectively respond to behavior.
- Help family members identify and treat their own issues.
Family Systems Treatment
We look at the recovery process for family members as being parallel to the recovery process for the identified patient. Our definition of family extends to include those who have important roles in the identified patient’s life and who are impacted by that person’s behavior. Our family treatment programs help those people realize that it’s not just about their loved one getting well, it’s about them getting well too.
Family systems theory7, which was developed by psychiatrist Murray Bowen, views the family as an interconnected emotional unit with complex interactions. All families develop rules and roles, and generally these roles provide stability. They are communicated in multiple ways within the nuclear family unit, and may be handed down through generations.
With a little thought, it’s likely that you can easily come up with rules that you got from your family. They may be as simple as always washing your hands before a meal or more complicated, such as rules around religion or tradition. Many rules are unspoken. Some of those unspoken rules may even contradict the stated rules. Honesty is a good example. Most parents tell their children it is important to be honest. Yet virtually all of those families also have rules that include not telling the truth:
- “Don’t tell Grandma that Dad lost his job.”
- “No, I’m not mad/sad/upset.”
- “We don’t talk about your mother’s drinking.”
Some of these rules may never be stated but are nonetheless clearly communicated.
Family systems are disrupted and rules and roles are impacted when the family faces a crisis — trauma, medical issues and losses, accidents, chemical use / chemical addiction, behavioral addiction (sexual, gambling, eating disorders, digital addiction, etc.) among others. When rules and roles are impacted, the entire system attempts to find a new equilibrium, causing a variety of shifts, both intended and unintended. Those shifts affect each member of the family and are communicated to children and often handed down through generations.
If chemical use or other high-risk behavior is present, the family has to develop strategies to survive that behavior and its attendant crises. Most of the time, a family does this by simplifying or reducing the level of input that needs to be managed.
One way of simplifying is to limit the family system’s emotional range. In other words, a family “decides” (without discussing it) to not feel any emotion that is uncomfortable in order to avoid the unrelenting fear and pain that often comes with substance use disorder. It’s not uncommon in families like this for members to focus only on the positive aspects of their lives and deny anything negative.
In the long term, this behavior reduces safety for the family system and creates additional problems, building on the difficulties that already existed because of the substance use/compulsive behaviors. Not only does the family not deal with the emotional pain, they have no way to develop the necessary skills and tools to work through the problems because they don’t acknowledge that there are any.
One of the most common questions family members ask when we explain the need for them to come for treatment is “Why me? I’m not the one with the problem.”
Sadly, that’s not ever true. In any family where a member has a substance use disorder and/or a mental health issue, every family member is impacted. Without treatment, family members do not have the opportunity to heal and it’s unlikely that the family system will change:
- The need for healing: Many times the energy and focus has been on the identified patient and other family members’ needs are overlooked. These family members need the same level of time, attention, and healing, as they have been affected by the cycle of the family trauma in very similar ways to the identified patient. We also find that if left untreated, the family members will likely try and return the entire system to the previously determined equilibrium, keeping the family stuck in the ineffective cycle. This is true even when the identified patient seems to be returning to a more desired level of health.
- Family dynamics support either recovery or relapse: If the identified patient does not believe the family system is changing, they are less likely to fully engage in treatment. At times, this can be due to fear: “If I change, and they don’t, will I still fit in my family?” This is not entirely unfounded. It can also be a way out: “They tell me I have to change, but they’re not, so they really don’t mean it.”
When words and actions do not match, we typically believe the actions, not the words. Therefore if the actions of the family system do not change, it remains clear to all involved that change is not going to be sustained.
Although family systems therapy emphasizes the family as a system, this should not be misconstrued as blame. The family did not cause the identified patient’s substance use disorder. Rather, family systems work enables family members to:
- Step back and see how family histories and experiences and the messages that were internalized as a result affect the family as a whole and each member individually.
- Understand how family interactions inside the family and with others outside the family are shaped by the family system and how they interpret their experiences through the lens of the family “story.”
- Develop their own competency and strength by owning and experiencing their own emotions and supporting other members of the family to do the same.
A family systems approach supports the family in recovery and gives them the tools and practice to be able to navigate the new family system in way that is sustainable. Those tools include new communication skills, how to work together, and how to resolve conflict in a healthy way.
Family Involvement Key to Patient’s Recovery
Our core belief in the value of family systems therapy is the reason we ask that families commit to treatment and education along with their loved one. If someone comes to us and says, “Take our loved one and we don’t want to be involved,” Caron Renaissance is probably not the right program.
A customized approach to family treatment is essential to fully address the unique needs of each family. We include all forms of onsite and distance family work in a patient’s treatment to allow for the maximum effectiveness and impact.
The core of the family work we do is to provide families with a clear and objective look at the family system:
- Rules and roles
- How the family system currently functions
- The issues that have derailed healthy functioning
As that picture becomes clear, we work with the family and support them to find new and healthier ways to relate to one another and contribute to healthy family functioning.
The process has two parts:
- Education: Families learn about substance use disorders and related behavioral conditions and family members’ role in the system.
- Emotional understanding: Then we move from the head to the heart—taking that intellectual understanding and helping families to internalize it emotionally so the family and each member can move forward with tools to deal with conflict, pain, disappointment, sadness, etc. when they come up.
Our family program includes multiple phone calls per week (as well as video conferencing when needed), communication via an interactive online portal, treatment assignments and readings, recommendations for therapy, and support groups.
Components of Family Systems Treatment
Each family works with the clinical team at Caron Renaissance to determine which combination of family services will best support their family.
Residential family programming (RFP): The identified patient and their family members reside together in the same clinical setting. Each family member works with a family therapist to identify their own treatment goals and expectations, and a parallel identification of what is needed for the system to function effectively. The goal is to help families begin to practice what they are learning during the course of treatment, like setting boundaries, and challenging family dynamics in settings where they can be clinically addressed/supported.
Three-day structured family workshop (FW): The family workshop is a clinical opportunity to work in a small group with other families to address individual and family systems issues. The family workshop is scheduled after families have begun to work with their family therapist. The workshop takes place in two parts:
- Family members work with other families and therapists to gain an understanding of how family histories and childhood experiences contribute to family functioning. Doing this in a workshop setting with other families allows family members to see commonalities and to recognize that they are not alone.
- Identified patients and families work together to:
- Set boundaries
- Have uncomfortable but necessary conversations
- Change ineffective and possibly damaging patterns of behavior and interaction
Clinical impact visits (CIV): If, during the course of the identified patient’s treatment, an issue comes up that requires immediate attention, we ask a family member (or members) to come in, including extended family members who may need to be involved. Participants may go to group sessions with the patient or our staff may recommend individual or family sessions or both. These examples illustrate how we use clinical impact visits:
- Siblings have work to do to develop their relationship.
- An issue has come up that needs to be discussed face to face, such as a family secret or a need to set a boundary.
- Aunts/uncles or other relevant family members need to come in to discuss the impact they have experienced with the identified patient.
- Ex-husbands or wives come in to address boundaries around co-parenting. Employers or trust officers come in to assess progress or set boundaries or conditions.
Each of these situations require different approaches – some would be done in the group setting to allow the patient and family to have group support and accountability, while others would be better suited to a session with the primary or family therapist. In every case, the situation that requires a clinical impact visit is discussed in advance, and clear clinical goals are identified to help determine which tool or tools will have the greatest likelihood of a positive outcome.
Personality Development/Emotional Maturity
Failure to Launch
Many of the adults that admit to Caron Renaissance have not made the typical transitions to adulthood, like graduating college, leaving the family home, becoming financially independent, entering the workforce, creating stable relationships, and finding meaningful employment.
We often see young and even older adults who emotionally are still in their teens. A hallmark of their behavior is extreme discomfort with and intolerance of uncertainty, ambiguity, and fear of failure. This discomfort leads them to avoid uncomfortable situations.
The root cause of this failure to launch stems from an interaction between two factors:
- An underlying mental health issue often unrecognized, misdiagnosed, or overdiagnosed
- An unstable foundation that underlies the maturity process
The drug/alcohol use and compulsive behaviors that are the reason they are in treatment are a lagging indicator of the dysfunction beneath the surface, rather than a cause of that dysfunction.
In addition, there is almost always a family system that has made that failure to launch acceptable at least in the short term. For many of these people, their powerful unconscious feelings of inadequacy, lack of self-esteem, and lack of self-efficacy have been reinforced both by their own inconsistency and by the people around them who have reinforced their belief that they aren’t capable. The fact that someone does for them what they should be doing for themselves is often the primary reinforcer of their belief in their own inadequacy.
We believe that the individual actually has the ability to change. The potential of people we treat is actually far higher and far greater than anyone has expected of them in quite some time.
The Dynamics of Dependence
Three dynamics reinforce the behavior, keep the dependent relationships intact, and perpetuate substance use/compulsive behaviors:
- Primary gain: The identified patient gets short-term relief of pain and anxiety and comfort from using drugs or alcohol or relying on a compulsive behavior.
- Secondary gain: The drug/alcohol use or behavior contributes to their inability to achieve the successes that mark the launch into adult life. In fact, their lives are often completely unmanageable. The lack of ability to achieve and the chaos that often surrounds them creates low expectations for them and reinforces a belief in their need to be taken care of. It also leads to blaming external factors for their own lack of success. This leads to an unconscious desire to continue substance use in order to avoid having to meet increased expectations, taking responsibility for actions, and living without the safety net they have depended on.
- Tertiary gain: The caretaker also benefits from the dependent relationship. For example, a parent may take comfort in the illusion of control that comes from managing the adult child’s bank account or having the person living at home. The relationship and the needs that come with it may also provide a welcome distraction from other dysfunction in the family. We often see situations in which the parent has a spouse who has a less severe addiction who sabotages the identified patient as they begin to get sober so that the spotlight doesn’t shift.
Unconscious Rather Than Conscious Dynamics
It’s key to keep in mind that almost all of these dynamics do not play out in people’s conscious minds and are rarely driven by malice.
They are, however, persistent. Even awareness is not capable of creating lasting change. To change these behaviors takes comprehensive treatment. After all, those behaviors are the only tools available to deal with the emotions that lie beneath the surface.
Caron Renaissance’s Treatment Model
Our goal is to move patients toward self-sufficiency:
- Healthy adult relationships
- Financial independence
- Setting and working toward education/career/vocational goals
The model we use works on two levels:
- Building self-esteem and recognition of what it takes to be an adult
- Working with them to chart their developmental milestones and how they reacted to them
Setting Expectations and Boundaries for Achievement
We begin by setting expectations and boundaries for small but necessary tasks of daily living, like:
- Getting up on time
- Cleaning their room and making the bed
- Grocery shopping
- Making their own meals
- Learning how to collaborate and how to ask for help
Achieving those steps begins to build a foundation of self-esteem for patients. Simulating what it takes to function as an adult while they are here gives us the space and opportunity to help them process the anxiety they feel doing those things as well as managing the crises and problems that will inevitably come up. While in treatment and with support, they can begin to achieve these activities on their own and understand how to deal with setbacks and problems.
We also work with them to understand that the material comforts they enjoy are primarily a product of someone else’s hard work, rather than their own. That understanding leads them to the knowledge of what it takes to live as adults who accept responsibility to take care of themselves and deal with consequences.
What we have found is that one of the most ego-strengthening endeavors that someone can engage in is actually going out finding a job on their own, showing up every day, and bringing home an honest paycheck. Realizing they can actually support themselves with that income, that they can do this on their own is a great gift. Many of our identified patients feel that if someone doesn’t give them what they want or need, they are not going to get their needs met. If they can leave knowing they don’t need dependence, it builds a foundation of confidence, self-esteem, and self-efficacy that will never be taken from them.
We encourage young people who are in high school or college to begin, continue, or complete their academic goals at a high school, community college, public and/or private university, vocational school, or graduate school. Setting educational goals and meeting them is another kind of ego-strengthening endeavor that builds confidence and self-esteem.
Recognizing What Led Them Here
We work with patients to do a sort of autopsy on their lives to date. This work is a key piece of our overall treatment model and the core of how we address underlying personality issues.
By looking at important developmental milestones from birth to present day and how they reacted to them, they can see how they managed or mismanaged situations, how they experience the world, how their experiences shaped their world view, and the tools they used, often maladaptive, to deal with those experiences.
The four lenses through which we view treatment offer our patients and their families a foundational base on which to build a framework for healthy functioning:
- Substance use/compulsive behaviors
- Underlying health and mental health issues
- Family systems
- Personality development/emotional maturity
By dealing simultaneously with substance use/compulsive behavior, mental/emotional health, family systems, and personality development/emotional maturity, they can move from unhealthy dependence to interdependence, from blame to responsibility, from a distorted view of the world and their role in it to a clear-eyed and honest one.
This approach to treatment is undoubtedly more complex than treating the most immediate and troublesome symptom of substance use/compulsive behaviors. However, by treating the substance use/compulsive behaviors as a part of a dynamic system that includes mental/emotional health, family systems, and emotional maturity, we are able to give our patients and their families a healthy way of interacting with each other and with the larger world. As with any other chronic, multi-systemic disease, substance use/compulsive behaviors can be managed in ways that allow for joyful, productive lives.
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2 Addiction Policy Forum. (n.d.). Retrieved from:
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4 American College of Physicans. March 28, 2017. Retrieved from:
5 National Institute of Mental Health. (n.d.). Retrieved from:
6 An introduction to co-occurring borderline personality disorder and substance use disorder. Fall 2014. Retrieved from
7 The Bowen Center. 2000. Retrieved from: