7880762_origOn sight it makes an awful lot of sense.  We are treating an illness that impacts a person’s mind, body and spirit.  Even the six dimensions of a person’s life that are proposed by the American Society of Addiction Medicine seem to examine every aspect of a patient’s life.  Their mental health, their drug use, their residence, etc.  We look under every rock as we assess our patients.
Once this is done, we find that there are typically identified problems in many if not all of these areas.  Doesn’t it make sense that we should put services in place for all of these issues under one roof?

On first glance it really does make a lot of sense.  During various periods of a person’s treatment it really may be necessary.  We need to house them in residential to get them out of unsafe situations.  We have to provide medical services and psychotherapy as well or they will not be able to change.  As businesses, treatment centers stand to make healthy profits if they can treat a patient from detoxification, through residential, to outpatient, and even to provide non professional services during outpatient such as sober living.

When this system works out well, it looks untouchable; like we should all be doing this, but what about the patient who has difficulty completing a treatment program?  He or she has frequently been kicked out of treatment for a range of potential issues.  They may have continued using in several programs once they reached the outpatient levels of care.  They may be fraternizing due to impulse control and abandonment issues during residential or even detoxification levels of care.  It could that trauma has made them highly resistant to treatment and their defensive guardedness is so activated that front line staff are unable to contain them with enough consistency for them to make it through the therapy.  Of course this patient doesn’t meet criteria for hospitalization usually, so the program eventually does what every other program has done; they kick them out.

No we have the dilemma of the “discharged patient.”  We often feel we have to do this to protect the milieu.  I mean, our other patients, the easier cases, they have rights too don’t they? They need to be protected from this person’s toxicity, and we sure don’t want to run off our well paying simpler cases do we?

It seems the only answer we have for these cases is to either blame the patient, or to say “they need long term treatment.  A year at least.”  This all sounds nice and makes us feel a little better as clinicians doesn’t it?  That poor chap just doesn’t have the resources so we couldn’t do anything for them.  Maybe they will “get it” someday we say to our colleagues.

So what happens to this patient when they are discharged from treatment?  Typically, they immediately lose access to all of the healthcare services they are receiving in one stroke of a pen.  They have lost their residence, and we have educated their families in enabling and instructed them to not take them back.  They may have been bonded to a group in therapy, but that is now gone as well.  Their individual therapist, or couple’s therapist was an employee of “the center” and is therefore no longer accessible.  Their psychiatrist and possibly their internal medicine doctor are both independent contractors of the facility and they are unable to continue treating the patient.  So what does the patient do in this situation?  They have nowhere to turn that they can see.  They can shop around potentially for another program if they still have any money left.  Of course, that is the exact same situation they were just unsuccessful in, and didn’t we ourselves tell them that insanity is doing the same thing over and over again while expecting a different result?  The logical course of action to our patients under these circumstances is to escape, to complete the relapse cycle, and to hope they are intervened upon once again, you know, after they have become willing.

Perhaps another option for this patient is to look at constructing a myriad of services from varied providers that are not contracted or otherwise committed to one another. In my experience, patients who have several paths back into recovery are more likely to have shorter, less intense relapses, and more likely to engage with their healthcare providers.  I had a patient once for example who was kicked out of three sober living homes while he was in intensive outpatient treatment with me.  This particular patient did not use in any of the four sober living homes he was in and even once slept on a park bench in an attempt to show his commitment to recovery to his parents, whom he had repeatedly gone to in the past to rescue him from consequences.  The patient was a professional, had completed law school and had another impressive undergraduate degree from a prestigious university.  One of his parents was a physician who was very adept at working with addiction and was even considered a specialist.  Because this patient’s sober living was not connected to his intensive outpatient program, we were able to work with him on referrals to other clean and sober residences on multiple occasions, and to continue to provide him with support and psychotherapy while he struggled to individuate from his parents.  This same patient is approaching a year of sobriety at this time.  His life isn’t perfect, but he has made it through the beginning and he remains stable.  He continues to see an individual therapist in private practice, and he has an outpatient psychiatrist that is also part of his treatment team.

The same patient described above, if discharged for his behavior from all treatment services in one fatal swoop, may have been lost in the wind for years.  The question I pose to anyone reading this article, is one of professional responsibility: Is this good treatment, or is it patient abandonment, or worse yet, systemic patient rejection?

About the Author
Kansas Cafferty, LMFT, CATC, MCA, is the founder and director of True North Recovery Services, an intensive outpatient program in Encinitas, CA. He has been in the field of addiction treatment since 1997.  Kansas also services as a Commissioner to the NAADAC National Certification Commission for Addiction Professionals in Washington, D.C.

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