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April 2021

Rules or Treatment Plans? Relationships and Hooking Up; Getting your head and heart around understanding addiction

In SAVVY, STUMP THE SHRINK & SKILLS, in this combined section, I address co-ed relationships and hooking up while in treatment; Treatment, Rules, or Discharge, not just about these behaviors but also how to address any behavior concerns while in treatment.

In SOUL, I wonder about how hard it is for Justice teams and treatment providers to pivot away from consequences and sanctions for addiction flare-ups; rules and regulations; and compliance and mandates for prosocial behavior. Talk to people in long-term recovery.

savvy, stump the shrink, & skills


Many of my trainings are to justice services teams (judges, attorneys, probation and parole, treatment court coordinators etc.) and to the treatment providers who provide mandated addiction and mental health treatment.

In 2021, we know so much about the science of behavior change (Transtheoretical Model of Behavior Change – Prochaska and DiClemente; Motivational Interviewing – Miller and Rollnick; Motivational Enhancement Therapy (MET); Cognitive Behavior Therapy (CBT) and the alphabet soup goes on and on).

Yet, one approach still predominates Drug Treatment Courts and many addiction treatment programs: Behavior Therapy techniques based on Operant Conditioning that focus on reinforcement, punishment, consequences, incentives and sanctions.

The implications of this include, but are not limited to:

  • A preoccupation with controlling behavior (drinking, drugging, angry outbursts, sexual behavior between clients etc.) rather than on learning what attitudes, feelings, thoughts and skills are needed to manage those behaviors.
  • A treatment court and treatment provider focus on program phases; compliance with rules and regulations and consequences for breaking the rules; and behavior contracts.
  • A practice of creating consequences for unproductive treatment outcomes like positive drug screens; inconsistent attendance and participation rather than assessing and improving the person’s individualized treatment plan.
  • Even if it is the treatment plan that focuses your work with the client, it is easy to get distracted by behavior that disrupts the group and treatment milieu.  
  • A participant and client attitude that the goal is to complete the program and graduate rather than to take responsibility for changing their attitudes, thoughts feelings and behaviors that threaten public safety, safety for children and families, or whatever else in their lives that has been affected by addiction and/or mental health conditions.

I was reminded of this when I received a message from a residential addiction treatment program seeking guidance on best practices for co-ed programming in their treatment groups.  Their earnest question was what to do about their facility that separates the residences of the men and women with locked doors but combines them in treatment groups.  They are concerned about relationships forming between the women and men.

In Tips and Topics July 2015, I addressed this concern in a STUMP THE SHRINK question about mixed gender groups and What is your view on policies about treatment peers forming exclusive, romantic relationships, or plain old sexual intimacy (hooking up) in treatment?

a.    Should the relationship be prohibited and one or both clients be discharged (referred to another program?)

b.    Should the relationship be allowed, but the involved clients be separated into different groups? And then a focus of treatment is learning about healthy relationships, boundaries, etc.?

c.    Or some other option?

In this April 2021 edition, I revisit Tips on this question. This also addresses the still predominant Behavior Therapy techniques based on Operant Conditioning and the focus on program phases; compliance with rules and regulations and consequences for breaking the rules; and behavior contracts.

Tip 1

Think about how you deal with emotional, behavioral and cognitive issues that are potentially disruptive to the group and treatment milieu.

I view all emotional, behavioral and cognitive problems as treatment issues that need to be dealt with in the context of an individualized treatment plan. That plan should be frequently and collaboratively changed depending on what is working well or not working well in the client’s progress in treatment. 

So in this case, if peers are forming relationships and hooking up, that is behavior that is going to happen while a person is in treatment and certainly happens when people are not in treatment. I suspect that for many people in treatment the relationships and sexual behavior they get into has created problems in their lives before – both substance-related and non-substance-related.

In outpatient and residential treatment, we have an opportunity to create: 

  • A safe, therapeutic environment. 
  • A therapeutic milieu that seeks to engage and attract people into an exploration of what has worked well for them before and what has not worked well.
  • An opportunity that allows clients to practice and develop new and healthier ways to deal with their behavioral health problems. 

We have had a tradition in addiction treatment and sometimes in mental health too, to focus on creating a safe environment by having rules, policies and consequences if clients break the rules; behavioral contracts; set back a level or phase in residential settings; loss of privileges; writing tasks; separating people into different groups; discharge etc.

We need to rethink our attitudes about what treatment is meant to do: 

  • Meet people at the stage of change they are at (what is the person at Action for; and what are the issues they are perhaps still in a Precontemplation, Contemplation or Preparation stage of change?).
  • Help them self-identify and own the issues that keep “shooting themselves in the foot” and are counterproductive to recovery and getting what they want whether that be health and wellness; or getting their children back; or getting off probation; or keeping a job, relationship or housing; or being sober and embracing recovery or whatever brought them to treatment.
  • Work compassionately with them to facilitate a self-change process using a collaborative, accountable treatment plan.
  • Fashion with them an updated treatment plan that changes in a positive direction whenever progress in stalling or new issues arise e.g., exclusive relationships and sexual behavior.

Tip 2

Help clients assess and evaluate the “differential diagnosis” of their emotional, behavioral and cognitive issues and the effect on their lives.

Talk with the clients in the exclusive relationship, but also with all the peers in group about the dangers of getting distracted by exclusive relationships and sexual behavior; and how this has in the past, does and can de-focus people from recovery and what they need to do to embrace new ways of being and doing. 

1. Engage the group in talking about where this has this been an issue in other peers’ lives and what they learnt from those experiences.

2. You could also talk about the dangers of forming intense new relationships early in recovery, especially if the new “love of my life” is also new in recovery and may even be less interested in recovery than me. 

3. You could talk about how easy it is to turn to relationships and sex as a way to deal with pain e.g., regrets of past mistakes, lost relationships and jobs, mental health issues.

4. Or identify how sex or a new relationship can avoid the hard work of recovery and help avoid taking “a searching and fearless moral inventory of ourselves” (Alcoholics Anonymous 4th Step).  It can be hard to look at your life whether in addiction or mental health treatment.

5. Help identify if certain mental health issues are contributing to such behavior e.g., unresolved issues with parents; or trauma or sexual abuse.

In other words there is a whole differential diagnosis of what forming relationships and sexual behavior can mean. These are assessment and treatment issues to be opened up for the clients involved. There is also a rich opportunity for the other peers in the group to explore these issues for themselves for “there but for the grace of God go I.” 

Tip 3

Consider what happens to treatment if the focus is on rules, consequences and discharge.

You can “prohibit” the exclusive relationship and sex, but are you also going to “prohibit”:

  • Substance use and relapses (we still do this often and I have written before about discharging people for having the symptoms and signs of their addiction illness).
  • Angry outbursts.
  • Cravings to use with irritability and isolating behavior.
  • Disrespectful talking and interactions with peers and staff.
  • Hanging out with drug-using friends.
  • Telling war stories about drugs etc. etc. 

Treatment is not about us making people behave; it is about helping them to make the right decisions in the dark of night when nobody is watching. If people do the right thing only when in our program, have we helped them to help themselves when we are not around? Have we facilitated a self-change process that can enhance sustainable recovery? Or have we externally imposed compliant behavior that too easily falls away when “graduated” from treatment?

Tip 4

When is it appropriate to discharge people for their behavior?

There may be clients who say they want treatment (perhaps mandated but just “doing time” in a treatment program) but then occupy and distract themselves by forming relationships and hooking up. They are not in good faith looking at what their behavior means and what the negative effects are on their life and on others’ lives. Just sitting in a chair is not doing treatment and they are not choosing the work of treatment and you can talk about discharge. 

  • You would be discharging them not because of bad behavior or breaking rules, but because they are not being open and willing to change their treatment plan in a positive direction. They have a right not to do treatment; and you have a right to keep the treatment milieu therapeutic and “discovery” and “recovery”-focused.

If a client is a sexual predator focused on disrupting treatment for themselves and others by forming relationships and hooking up, then discharge is appropriate because this is a treatment place, not a dating place. 

  • But if such behavior is part of the person’s biopsychosocial-spiritual illness with implications for addiction, mental health and physical well being, then these are important treatment issues needing more assessment and treatment; not discharge or hoping you can just prohibit human behavior. If the person is willing to deal head on with this behavior and attitudes, then treatment is what the person needs and to discharge them for having problems to work on doesn’t fit my vision for treatment.

A friend and colleague recently said this:

“My mantra is, ‘this is the place where you don’t have to be at your best.’ If people are out of sorts or have a bad hair day, all the more material for the staff to work with.” 

Andrea G. Barthwell, MD, DFASAM

Oak Park, Illinois

If we expect people to behave and be at their best, then they probably don’t need treatment and have nothing important to change.

Tip 5

Treatment Plan Strategies for Working on Relationships and Hooking Up

When the focus is on treatment and change, not compliance with rules and regulations, behavior problems are learning opportunities to improve attitudes, feelings, thoughts and skills.  If clients are “doing treatment and change” not “doing time” they would be willing to change their treatment plan in a positive direction by such strategies as: 

1. Talk with a counselor about where relationships and hooking up has affected my life and addiction in the past and share that in group to get feedback.

2. Explain in group what is so great about the new, exclusive relationship and get feedback on whether this relationship will help, hinder or jeopardize recovery.

3. Have a trial of staying away from the other person for a week; and each person in the relationship talk in group about what that was like.

4. Share in group examples of relationships they got into quickly and sexual behavior that contributed to problems in their life, both addiction related or not. 

There would be many other treatment plan changes collaboratively inserted into the plan once more assessment with the client was done.

If the client is willing to do this work, treatment continues. Use the power of the people in the group together and not separate them or discharge.

Note of caution:

You’ll notice that I define good faith working in treatment as “being open and willing to change their treatment plan in a positive direction.”  Or as they say in AA “progress, not perfection”.  We would like every person from Day 1, to be: 

  • perfectly sober with no cravings or impulses to use and no actual use
  • perfect in delaying gratification for relationships and hooking up and totally focused on recovery
  • perfectly non-depressed, non-psychotic; non-anxious; non-manic
  • perfectly non-angry, irritable and isolating
  • perfectly non self-mutilating, suicidal or impulsive etc. etc.

But if our clients and participants could do all that, they wouldn’t need our help in their self-change process. So if your impulse is to change their treatment plans by inserting: 

  • Bob and Jane will end this inappropriate relationship and sexual behavior and focus on recovery” and then,
  • Discharging Bob and Jane when they break their treatment plan, that is “perfection” not “progress”. 
  • That is not changing their treatment plan in a “positive direction”, that is expecting perfection and the final changed behavior immediately.


Soon after I graduated from my specialty training in psychiatry, I was assigned to an addiction treatment team.  Even though I received excellent training in mental health diagnosis and treatment in one of Harvard Medical School’s programs, I did not get good addiction treatment training back then. So I had to get on-the-job training from addiction counselors who helped me learn and un-learn attitudes, knowledge and skills about addiction treatment.

One day, a counselor asked me: “Dr. Mee-Lee, even though you don’t have a substance use problem, is there anything that you keep doing that you want to stop, but keep doing against your better judgement?  I want you to know how it feels for our patients with addiction who try so hard, but just don’t seem to be able to stop using.” 
I thought for a second and joked: “No, I think I’m pretty perfect really!”

But then I thought of those repeat speeding tickets; broken promises to do more exercise, eat less, read and meditate more……not as devastating as the disease of addiction, but “There but for the grace of God, go I.”
Then I see how hard it is for justice teams and even addiction treatment providers to pivot away from a focus on: 

  • consequences and sanctions for addiction flare-ups
  • rules and regulations and behavioral contracts
  • compliance and mandates for prosocial behavior.

I wonder:

  • Is it too hard for people to understand addiction as the “treatable chronic medical disease…” that the American Society of Addiction Medicine describes? 
  • Are we still in the grips of discrimination and stigma about addiction as willful misconduct and bad behavior?
  • Is it so hard to appreciate the bondage of addiction that leads people to do so many things against their better judgement and fail to make will power work over a chronic disease?

When I see how hard it is for anyone to get their head and heart around the self-defeating patterns that enslave people with addiction, I make a suggestion:

  • Ask any judge, lawyer, physician, neighbor or friend in long term recovery: 
  • “In the throes of your active addiction illness, did you ever lie about your substance use; act against your better judgement in a way that jeopardized your career, health, relationships or freedom?  
  • Were you able to be abstinent from the very first day of treatment or a decision to stop using, never to have a flare-up of use even after several months of sobriety?”

Addiction certainly is a “cunning, baffling, and powerful disease”.

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