Nurse Practitioners Guiding Patients on the Road to Recovery
Learn more about the subspecialty of addiction nursing and how nurse practitioners can aid patients in substance use recovery.
The Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as “a process of change through which individuals improve their health and wellness, live self-directed lives and strive to reach their full potential.” It is estimated that 7 in 10 adults with a past substance use problem consider themselves to be recovering or in recovery, and “50.2 million American adults considered themselves to be in recovery from their substance use and/or mental health problems.”
The American Association of Nurse Practitioners® (AANP) is committed to supporting nurse practitioners (NPs) as they treat substance abuse in their communities and aid patients on the road to recovery. In observance of National Recovery Month, AANP spoke to AANP Psych and Mental Health Community
co-chair Susanne Fogger, DNP, CRNP, PMHNP-BC, CARN-AP, FAANP, FAAN, about her background as a psychiatric nurse, her specialization in addiction nursing and her expert advice on aiding patients with their recovery.
Q: What was your nursing journey like, and how did you come to work in mental health?
Susanne Fogger: I attended a diploma program in Boston (Peter Bent Brigham School of Nursing), which was heavily adult med-surg. While I anticipated I would do great anywhere, understanding mental illness was the challenge that intrigued me the most. So, I served in the U.S. Air Force as a psychiatric registered nurse, where I was assigned to an alcohol treatment unit. Through formal training and discussions with my patients, I discovered just how powerful the neurochemicals of addiction are and learned how to treat addiction.
Years later, I moved to a rural part of Louisiana. With the closest psychiatric hospital more than 60 miles away, I ended up taking a job in home health. Because the home health agency was in a rural area, they didn’t have enough psychiatric patients for me to see psychiatric patients alone. They told me, ‘You're going to have to see medical patients, too.’ I didn’t have a lot of experience with medical patients, but I needed the job, so I learned to be skilled in physical assessment.
This proved beneficial, since addictions nursing requires you to physically assess the individual that you're working with, particularly if they're in acute withdrawal. Often, individuals with substance use have underlying medical problems, and understanding how those problems interplay with the addiction is key in helping them reach recovery. Being a psychiatric nurse helped me to see the whole patient, both physically and mentally, and gave me the confidence to become a NP.
Q: How would you describe the subspecialty of addiction nursing? What advice would you give for new NPs looking to specialize?
Fogger: My first job out of NP school was working in an addiction recovery unit doing physical assessments and detox. It was kind of like a trial by fire. In that role, my biggest eye-opener was realizing how connected one’s mind and body are. So, I would recommend that NPs wanting to specialize in addiction nursing gain medical experience as part of their journey.
If you want to begin to care for people with addictions, start asking the right questions. Patients with substance use disorders are often hidden, as addiction is highly stigmatizing and self-stigmatizing. There are people in your community and in hospital beds that have an underlying addiction issue, but they're not going to talk about it unless you ask. So, I would say to learn the fine arts of interviewing so that you can ask the hard questions.
It’s important to be able to utilize motivational interviewing, give people information and then move on if they are not ready. You need to recognize that if a person says, ‘I’m not ready to give up smoking,’ you can argue all afternoon about why they should quit smoking. But if they say to you, ‘I'm not ready to quit smoking,’ then continue the discussion about something else. It’s a matter of recognizing when people can hear you and when they're not going to. Keep moving in your assessment but let them know ‘Well, we can talk about this again next time.’
Q: As a clinical expert and educator in addiction nursing, what tools, techniques and strategies do you think are key to achieving recovery?
Fogger: As you’re working with patients, it’s incredibly important to understand Prochaska and DiClemente's transtheoretical model and its stages of change. It’s a model that’s helpful because it recognizes the fact that people don't change in a linear manner. As providers, we have to encourage progress while also acknowledging that sometimes people fall backwards in the process.
Sometimes, people can do well with change and then stress happens. That person learning a new behavior has a brain that knows what has worked in the past to manage stress and will unconsciously present those old options as a solution to cope. This can be hard to get around when the person is struggling and doesn’t have the skills at the moment to figure out a new way to reduce their discomfort. For example, their brain knows that if they have a drink, then they'll feel better, or if they use an opiate, it'll make the pain go away. In mental health and addictions, stress makes everything worse.
While not all people benefit from going to Alcoholics Anonymous (AA), it does work for some. One concept that can be useful in helping someone recover is an old AA saying, “Recovery requires you to change your playground, playmates and playthings.” It’s really difficult to stay away from substances if you're hanging out with old friends who are still using them.
But I think the thing that's the most hopeful for people getting into recovery is that it isn't one-size-fits-all. It's individualized and it requires providers to recognize that the patient must find their own way. Recovery is more than just not using substances — it is about becoming a better and healthier human being. Although the “gold standard” of recovery expects the individual to not use any addictive or mind-altering substances while they're in recovery, total abstinence may not be the one and only goal.
People can be helped to reduce their substance use or change how they use. Working with people requires flexibility to meet them where they are, as some won't even entertain the idea of recovery if total abstinence is the one and only goal. Recovery is a matter of improving a person’s health and helping them move toward self-fulfillment. The concept of total abstinence doesn't necessarily apply to all people — and people can be in recovery even though they're not totally abstinent from all substances.
Q: SAMHSA defines the four dimensions of recovery as health, home, purpose and community. With only one of these four dimensions taking place in the clinical setting, how can NPs best check in on patients to ensure a successful recovery?
Fogger: As providers, we can have conversations with people about how things are going with their health, their home, their purpose and community. But to do that, the individual who's asking the questions has to be open to hearing about things that are not going well, as well as those that are.
That’s tricky, since we can be biased, and we want to hear our patients doing well — and the patient wants to comply. They won't tell you unless you ask, ‘What's not going so good?’ Discussing the four dimensions of recovery with honesty is possible provided you have the individual’s trust to hear what they have to say, no matter what it is.
Q: You are a veteran, and one of your areas of expertise is veterans’ mental health. How can NPs support veterans and other vulnerable populations to improve their mental health and achieve substance use recovery?
Fogger: Start by asking ‘Have you ever served?’ If they say yes, what kind of a job did you do? The type of job that the individual had is going to help you understand a little more about who this person is and what kind of experience they've had. Not everybody in the military experiences combat. For example, a person who was deployed to Iraq may be exposed to a whole lot more than somebody who never left the country.
The other important thing is to be respectful. Consider that the individual may have trauma but may not tell you about it until they trust you. If you ask someone on their initial interview, ‘Have you been exposed to any trauma?’ they may not tell you. They’re going to say no and close the conversation. However, I've had experiences with individuals who, after working with them for three or four years, trust me enough to tell me about the painful stuff that really bothered them. Then, we can begin to work on it.
Q: Finally, in what ways are NPs best suited to positively impact mental health and substance use recovery?
Fogger: Nurses have a reputation of being trustworthy. No psychiatric care that's worth its salt is going to get anywhere if there's no trust. Improving access to care is important, as NPs end up going places where there are no doctors. For some patients, an NP may be the only provider they’ll see. In small communities, NPs are pillars of the community that know the culture and norms of the area. They may treat patients across generations — that trust is vital.
Additionally, NPs often hold the belief that there is the possibility for a better life. As psychiatric and addiction providers, we know we can't change people. We coach people, we're guides, we're healers, but we can't change anybody. But instilling patients with the hope of recovery is something that empowers them to better health.
You know the old joke about how many psychiatrists does it take to change a light bulb? I'd say, how many psychiatric NPs does it take to change a light bulb? The answer is none — because the light bulb has to want to change. Sorry, couldn’t resist.
Improve Mental Health Outcomes With Help From the AANP Communities
If you’re interested in psychiatric-mental health and recovery, the AANP Psych and Mental Health Community offers a unique opportunity to collaborate with colleagues who share interest or clinical expertise in psychiatric care. As an AANP Community member, you’ll have access to a cutting-edge, online forum where you can engage in discussions, document sharing and knowledge exchange with your fellow NPs.