MADIGAN ARMY MEDICAL CENTER, Joint Base Lewis-McChord, Wash. -- What does it take to get on track when life's trials have led to the misuse of alcohol and other substances? The answer to that question is likely as varied as people themselves. For some, a 28-day stay in Madigan's Residential Treatment Facility aids in altering patterns of thinking and quells destructive behavior.

The RTF at Madigan was developed three and a half years ago to provide a final stop for service members who need intensive, inpatient treatment to battle their reliance on substances.

"What separates our program is, when other programs address substance use issues, they address the symptom of substance use. Our program looks at the core of it," explained unit psychologist Dr. Julie Oberhausen.

How did the RTF become the distinctive program that it is?

Impetus and expertise

A major reason for the establishment of a residential treatment program on Joint Base Lewis-McChord was that sending service members to external facilities in the TRICARE network was costing $2 to $3 million per year. Madigan's residential treatment facility is one of only three in the Army and six total in the Department of Defense.

The first RTF at Fort Gordon, Georgia, was established a half dozen years ago and provided the model for Madigan's. Since Madigan's RTF started at the beginning of 2016, it has seen changes to its staff and curriculum.

"The program is entirely evidence-based now and follows the clinical guidelines of both the DoD and the VA," said Richard Benson, a social worker with the program.

"Our providers are all licensed and have specialties in addiction, which is nice because we all speak the same language and have the same experience," Benson added.

He noted the only exception in licensure among providers is the psychologist who does have years of experience with addiction treatment.

The program's staff consists of providers to include a psychologist, therapists and a social worker and nursing staff that includes psychiatric technicians like Linus Agu, who has been with the program since its inception.

Agu has two master's degrees and an associate license to be a family therapist. He is not unusual for the staff who are well-educated and highly invested in the psychiatric field.

That expertise is needed as residential treatment provides the highest level of care for substance use disorder and requires referral and the involvement of the service member's command.

This program will help keep some people in their military careers, while others will be separated from service. Either way, set up for future success is the overriding goal of the program, said Benson.

Unique with a purpose

Madigan's program is different from most RTFs to be found both within the military and outside it.

One of the aspects of the RTF that is unique is its autobiography. Other programs do have this element where patients come into the program and tell their story of substance misuse. But, the RTF here delves deeper by adding a process group after the initial autobiography session.

When asked for a highlight of the program for them in an exit survey upon graduation, one patient described it as useful because of, "The very nature of the autobiography and its complex dynamic. Thought processes, beliefs, and childhood trauma are presented in such a manner that necessitates rigorous honesty and authenticity. Not only does it 'break the ice' of sharing uncomfortable memories and feelings with strangers, it allows other patients the ability to see patterns of misrepresentation of past experience as well as allows them to think and question the information being presented in an insightfully critical manner."

Oberhausen breaks it down as autobiography is the identification and process is the examination.

"It's pretty intensive. There is fear leading into it, distress during it, and relief following it, with understanding," she said.

She guides the group through these sessions with the assistance of techs and sometimes nurses. It is the techs who are the patient's go-to person on the program staff.

Each day every patient has a tech assigned to them. They have heavy interaction with the patients, for whom they advocate and act as sounding boards and assistants for all their needs. As Agu described it, the techs are, "in the trenches with the patients."

One of their functions is to accompany the patients on outings. They have gone all around the Puget Sound visiting all sorts of settings from nature trails to farmers markets. They also engage in various community volunteer projects. Importantly, they also attend Alcoholics Anonymous meetings in a variety of communities to give the patients a flavor of the different groups they can find.

"These outings are not just for fun; there is purposefulness behind it. In part, to help reintegrate the Soldier into social settings without alcohol or drugs," said Dr. Aaron Edwards, a psychiatrist and the program's medical director.

Staff dedication

The program's staff ensures that the patients are attended to in every possible way.

"Our staff, every one of them, we come in on holidays, make sure they have activities going," said Edwards. "I love the staff," he added.

Quantitative data displaying outcomes for a RTF are hard to come by. Numerous staff members point to the positive feedback they get on exit surveys and in encounters with past patients.

Providers, staff and even current patients can all share stories of how they run into past patients who offer positive feedback. Oberhausen has had providers come up to her at conferences and tell her how effective the program was for patients they see currently on an outpatient basis.

Edwards comes in at 5:30 a.m. to exercise with the patients twice a week. Having been deployed many times, he utilizes the combat stress control model used in deployment where the commander exercises with the service members so the boundaries are broken down.

"The patients really seem to open up once they see you're willing to work out with them and be with them. It's also just being present and being there for them," he said.

A graduate's exit survey echoes the impact of his dedication as they stated, "Dr. Edwards went out of his way to keep us motivated and with a positive attitude daily."

Watching Edwards lead a workout session is hardly just a matter of being willing to sweat with them, he endeavors to work harder and longer than anyone, leading by example. Other providers join these workouts at times as well.

Lasting impact

Talk to any staff member and the appreciation for the valuable impacts of the program on its patients is evident.

"I believe in our program; it is a great program. I feel like we do great work here," said Fiona Gbehan, a registered nurse who has been on the unit since its start.

Sometimes, the uniqueness of the program makes its greatness harder to instantly see than another one. Seeing a doctor pump a chest and save a life in the emergency department is obvious. The RTF unfolds its life-saving care over time and more subtly. From the outside, that is; everyone on the inside is clear on its value.

"I love the population I'm working with, I enjoy them. I like being able to spend four weeks with them; that's unique. To be able to see the growth they have emotionally and physically, it's very rewarding," said Edwards.

Juliana Whitaker, a registered nurse who is studying to become a psychiatric nurse practitioner, added, "It's just really great to see the progress that they make and the difference that the staff here makes in their lives because this affects the rest of their lives."

"When they first come in, you can see the distress," Adu added. "By the second week we can actually see the physical change in their body."

"As with anything, there are ups and downs, but I think that we do help," added Gbehan.

Proof of concept

The RTF has just completed a site assessment visit conducted by the Army Medical Command.

"They just went through a comprehensive review and they got glowing feedback," stated Col. (Dr.) Matthew Cody, the chief of Inpatient Behavioral Health who oversees the program.

This is a program and a unit on a hospital floor that is like no other in the medical center.

"Every time people hear what we do, they get it; and they like it," said Oberhausen.

The assessment team agreed. They acknowledged that Madigan's program provides the most thorough treatment possible. It also encouraged further support to include additional staffing and a dedicated chief to be at the table with hospital and installation leadership advocating solely for this program.

"The program works if it's allowed to work," said Gbehan. "Our patients matter."

The statements of two graduates may sum up this program best.

"I feel like I have the tools to finally start getting better in life and have a fighting chance against my illness. I believe this was the best possible treatment. I am forever thankful," said one.

Another echoed those sentiments. "Life-changing program. I've never felt so well taken care of in my entire life. Staff goes above and beyond to meet every need of the patient. Obvious that these are professionals, experts in their field. Thank you for providing the United States military with such an exceptional, successful program."