APEX therapy may not provide direct answers when recovering addicts and alcoholics question their newly sober identities, but it can provide some clues.
Once the drugs and alcohol are stripped away in addiction treatment, patients often face something of an existential crisis. “Who am I,” they wonder, “if I’m not an addict or an alcoholic?”
It’s a legitimate question. Writing for the online news site Vice, Hannah Brooks has documented her own journey out of heroin addiction [1]: “Who am I without drugs? … My identity had become so entwined with heroin that I had normalized it. It was only occasionally, in a moment of clarity, that I realized just how abnormal being a heroin addict was.”
Answering that question is crucial if recovery is to be sustained: In 2011, writing for the peer-reviewed journal Current Psychiatry Reports, Rajita Sinha wrote that “recent estimates from clinical treatment studies suggest that more than two thirds of individuals relapse within weeks to months of initiating treatment.” [2] While it can certainly be argued that the willingness to get clean and stay that way might have been lacking, a great many addicts and alcoholics return to drinking and using because the void left once the substances are removed is never filled.
Or rather, they’ve not been given the tools to fill it. That’s where APEX therapy can make a crucial difference.
The roots of APEX Therapy
APEX stands for “Assess, Plan, Execute,” and as a therapeutic process, it draws on certain fundamentals of occupational therapy. That’s Dr. Ryan Johnson’s field of expertise, and as one of the pioneers of APEX Therapy, he started out with a blank slate when he carried out his experiential internship at a drug and alcohol treatment center outside of Knoxville, Tennessee.
“The idea was to develop a program, but I started with a needs assessment to figure out what needs were there and which ones weren’t being met,” Johnson says. “I talked to people in the Sober Living community, in the Intensive Outpatient Program, in the Recovery Renewal Program and in the Young Adult Program to gather what were commonly discussed needs in the community. What I found was that they wanted more experiential assignments, and that young adults who transitioned from residential inpatient treatment to Sober Living had the hardest time of any group.
“There was a lot of relapse and setbacks, and what we found was that those young adults suffered from a lack of work skills and financial skills. We started digging deeper and looking at the research into those particular areas and the different data, and we narrowed the focus down to the work and financial skills as a focus of an occupational therapy program.”
What Johnson and his collaborators discovered, he adds, was that few research modalities addressed these needs within the field of substance abuse treatment. The need has been recognized — “occupational therapy is uniquely positioned to assist people who are struggling to recover from substance abuse, by helping them to reestablish the roles and identities most meaningful to them,” according to the American Occupational Therapy Association [3] — but specific therapeutic modalities, especially geared toward young adults, are hard to come by.
Johnson consulted with Michelle Ullom, a Licensed Alcohol and Drug Counselor and Certified Peer Recovery Specialist at the facility, as well as with individuals at a career exploration program at the University of Tennessee Knoxville. From there, they turned to MOHO — the Model Of Human Occupation, a program designed by the University of Illinois at Chicago researchers.
MOHO, according to the university’s website [4], “seeks to explain how occupation is motivated, patterned, and performed. By offering explanations of such diverse phenomena, MOHO offers a broad and integrative view of human occupation. Within MOHO, humans are conceptualized as being made up of three interrelated components: volition, habituation, and performance capacity.”
The nuts and bolts of APEX Therapy
“First, you’ve got to convince these individuals to want to do something different, and that is volition,” Johnson says. “The next step is habituation, which is developing habits and behaviors that follow those beliefs, wants and values. And the third, performance capacity, is the ability to live with these new values.”
While it sounds simple on the surface, the peccadilloes of the addicted mind make navigating those three steps more complex than it might seem. APEX incorporates a number of other modalities, including John Holland’s Theory of Career Choice, which was first published in 1959 and postulates that “most people resemble a combination of six personality types,” according to a 2010 paper in the Journal of Counseling Psychology [5], and “each type is characterized by a constellation of interests, preferred activities, beliefs, abilities, values, and characteristics.” Assessments are used to categorize potential work environments that permit participants to “exercise their skills and abilities, express their attitudes and values, and take on agreeable problems and roles.”
“If you take the drugs away, an addict is just lost when it comes to figuring out who they are,” says Johnson, who contracts as an occupational therapist for the Knoxville-based company Functional Pathways. “Specifically, a lot of 18-year-olds don’t want to be in treatment, and their parents have perhaps done everything for them, so they don’t have any idea what they want to do or even what skills they might have. The unique thing about APEX is that we can use some of the maladaptive skills addressed in treatment and turn them into something positive. For instance, maybe you’re very manipulative and can talk your way out of anything. That might make you a good salesman! That’s a skill we can apply positively.”
Each APEX course, according to the guidelines written by Johnson and Ullom, begins with a motivational video designed to create a sense of hope — just because patients don’t know who they are or what they can do isn’t the same thing as being completely devoid of potential. The process is guided by the establishment of S.M.A.R.T. goals: Specific, Measurable, Attainable, Realistic and Timely goals, and how best to apply them in order to help participants achieve their ability to explore specific areas of interest.
“What I think is unique about this is that we’re taking actionable steps,” Johnson says. “There’s a website called O*Net [6], where we can plug in these variables and get a list of potential occupations. I remember one patient who discovered that he fit the parameters for being a firefighter. So we sat down and said, ‘OK, what does it take to be a firefighter? Let’s look it up.’
“Obviously, you’ve got to take a fitness test, and you’ve got to spend so many hours volunteering, so then we wrote very actionable goals, one of which was that he would go to the Fitness Center and run a mile three times a week. That’s the goal, and toward the end of the APEX therapy group, when they’re executing their goals, we do one-on-one: ‘Here are the specific goals. Did you follow up? What were the results?’”
From theoretical to practical application
The Execute phase of APEX Therapy involves “improving self-efficacy and developing skills required for career goals. This process includes ‘brainstorming’ work preparation skills needed to obtain a certain career as we as Communication, Social Skills, Physical skills and Emotional, Cognitive thinking skills needed for the career.”
For many people, the process of putting together a resume and a cover letter may seem like old hat, but Johnson and Ullom found that such basic skills were foreign to young adults recovering from addiction and alcoholism who, in many instances, had never applied for a job.
“How do we as professionals guide individuals to see themselves for who they genuinely are?” Ullom writes. “Young adults have trouble seeing themselves through eyes of greatness, and those who struggle with addiction can’t even begin to see themselves as worthy and capable. One of the goals of APEX therapy is to walk the young adult through the process of identifying their skills, whether the skills are through their work, their schooling or even their home life.”
It is, in a sense, a job training “boot camp,” with equal importance placed on self-worth and positive thinking as much as vocational accomplishment. For example, participants are walked through a mock interview process, “from the initial greeting of the prospective employer to the various strategies used for answering and asking questions and how to conduct oneself. The goal is to increase the likelihood of a successful interview for the individual.”
In addition, clients are given access to research schools that might further the education needed to pursue a desired career, as well as businesses and companies that might have openings in fields that are a step in those directions. Financial budgeting is an important component as well, because many young people emerging from the fog of addiction have little to know experience with money management.
And while such skills are practical, they also serve the dual purpose of complimenting traditional drug and alcohol treatment psychotherapies.
“Throughout the journey, the individual obtains a higher sense of self and achieves a sense of purpose for life in recovery,” Ullom writes. “The APEX program is self-incentivizing as the Young Adult gains an understanding of the possibilities they were unable to grasp while in active addiction.”
APEX therapy: Real world solutions
While still a relatively new therapy, APEX has achieved tangible results, according to Ullom. One young client, during the financial budgeting process, was astounded to learn how much money he could save once the amount spent on alcohol prior to treatment was removed as a line item. Another had long daydreamed of working in wildlife management, and APEX therapy, combined with addiction treatment, provided him with the incentive and the courage to obtain an internship in the field. Another worried that returning to nursing would be detrimental to her recovery because of the access to prescription narcotics; through APEX therapy, “this individual was able to research the various nursing positions that would not entail the degree of accessibility to medicines,” Ullom writes.
“When an individual enters treatment, they are most likely experiencing the consequences of their addiction,” Ullom writes. “Many patients have had to drop out of school or have lost jobs due to absences and behaviors. The young adult comes in reeling due to feeling like a failure. For many they are experiencing emotions for the first time in a long time due to the numbing effect of drugs and alcohol.
“Taking an individual from the point of despair to one of hope is a steady climb, one of encouragement and hope. Creating an atmosphere of believing in oneself again is paramount to the young adults’ future and recovery.”
“On the face of it, it seems like we’re trying to get people jobs, but for me, what I really understood this program to be is just to try and fan the flame of hope,” Johnson adds. “It’s so powerful to see the lightbulb go off when they understand that to get from A to B, you just have to take one, two or three steps. You’re trying to develop a desire to do something different, along with an awareness that they’re capable of doing something different.
“And when you give them the skills for those actionable steps, you’re able to break it down for them so that they don’t get overwhelmed. You show them that they can do something, take one step, just for today, and that makes it so much more approachable.”
SOURCES
[1]: https://www.vice.com/en_us/article/mbwbvv/who-am-i-without-drugs-imagining-life-after-rehab
[2]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3674771/
[3]: https://www.aota.org/About-Occupational-Therapy/Professionals/MH/Articles/RecoveryWithPurpose.aspx
[4]: https://www.moho.uic.edu/resources/about.aspx
[5]: https://www.counseling.org/docs/david-kaplan’s-files/nauta.pdf?sfvrsn=2