It's Time to Stop Kicking People Out of Addiction Treatment
http://www.addictioninfo.org/articles/2153/1/Its-Time-to-Stop-Kicking-People-Out-of-Addiction-Treatment/Page1.html
William White
William L. White, M.A., is a Senior Research Consultant at Chestnut Health Systems and the author of Slaying the Dragon: The History of Addiction Treatment and Recovery in America.
By William White
Published on 01/11/2008
A review of the addiction treatment literature reveals a number of key findings related to current administrative discharge practices.
A review of the addiction treatment literature reveals a number of key findings related to current administrative discharge practices.William L. White, M.A., Christy K. Scott, Ph. D., Michael L. Dennis, Ph. D., and Michael G. Boyle, M.A.
Originally published in Counselor Vol. 6 No. 2 April 2005.
Administrative discharge patterns
A review of the addiction treatment literature reveals a number of key findings related to current administrative discharge practices.
Definitional Problems: Discharge categories and their definitions differ across programs, but there is evidence that discharge rates by type of discharge vary across community-based and prison-based treatment programs (Pelissier, et al., 2003) and vary from therapist to therapist within the same treatment program (Najavits & Weiss, 1994).
Discharge Status and Clinical Outcomes: In adult populations, addiction treatment retention and completion are predictive of positive outcomes, and failure to complete treatment (including those administratively discharged) is predictive of worse outcomes (Price, 1997; Grella, et al., 1999;Wallace & Weeks, 2004).
The role of discharge status on adolescent treatment outcomes is less clear, with one study noting superior outcomes for successful completers (Winters, et al., 2000), and one study noting no significant differences between treatment completers and non-completers (Godley, et al., 2001).
Administrative Discharge Profiles: Adult and adolescent noncompleters are more likely to have clinical profiles marked by younger age, greater problem severity (although some studies report a positive link between severity and retention) psychiatric impairment (i.e., depression, conduct disorder, antisocial personality disorder, schizophrenia), history of perpetration of violence, less motivation for recovery, and less recovery supports in their family and social network (Godley, et al., 2001; Hser, et al., 1998; DeLeon & Jainchill, 1986; Agosti, et al.,1996; DeLeon, et al., 2000; Pelissier, et al., 2003).
Administrative Discharge Prevalence and Level of Care Patterns: At the present time, 18 percent (288,000 thousand) of the 1.6 million people admitted to publicly funded addiction treatment in the United States are administratively discharged (compared to 49 percent who complete treatment, 24 percent who leave against staff advice; and 9 percent who are transferred) (Substance Abuse and Mental Health Services Administration, 2002).
Rates of AD are not uniform across levels of care. The highest to lowest rates of AD are found in methadone maintenance (30.7 percent), long-term residential (24.8 percent), outpatient (23.7 percent), intensive outpatient (19.8 percent), detoxification (9.4 percent), short-term residential (9 percent), and inpatient hospital treatment (4.6 percent) (SAMHSA, 2002).
Common objectives for the use of administrative discharges In reviewing the literature and interviewing colleagues around the country about AD practices, we found five primary objectives that treatment professionals hope to achieve through the use of administrative discharge:
Objective #1: To protect the integrity of the treatment milieu. Administrative discharges are used to prevent and respond to disruptive behaviors that negatively impact the treatment environment. In this view, individuals who are acting out are sacrificed for the greater good of other clients. Many readers would concur that therapeutic milieu is a crucial but fragile dimension of addiction treatment that can be compromised or lost. The AD stands as the ultimate instrument for preserving that milieu, even if applied in an inconsistent manner.
Objective #2: To assure the best utilization of limited treatment resource. Administrative discharges are used to ration addiction treatment services to those who the treatment provider believes can most benefit from it. The AD practice assumes that programs have limited resources and clients who act out are wasting resources that more deserving others could be using. This objective is also met in some programs by discharging clients who cannot pay service fees on the grounds that the long-term financial integrity of the service organization takes precedence over the immediate needs of the non-paying client.
Objective #3: To protect the reputation of the treatment program. Administrative discharges are used to terminate services for clients who continue to use substances or exhibit other disruptive behaviors within the context of treatment. The assumption underlying such extrusion is that allowing clients to continue treatment while using would lead to a loss of community respect and support for the program.
Rumors circulating within the using community regarding toleration of substance use during treatment could also damage the reputation of the program in the eyes of its most important constituents, including more compliant clients.
Objective #4: To prevent the treatment organization and its staff from enabling clients. Programs that use AD to achieve this goal assume that anything short of severing the service relationship with the AOD-using client would, by protecting the client from the consequences of his or her actions, constitute a form of professional enabling. In this view, there is therapeutic harm for continuing to treat the AOD-using client and therapeutic benefit (a motivational “wake-up call”) resulting from treatment expulsion. Clients returning to treatment following AD who contritely confess that they weren’t ready for treatment and that they needed a dose of reality add anecdotal support for this argument.
Objective #5: To fulfill the ethical obligation of terminating and (at least nominally) referring clients who fail to respond to program services. The assumption guiding this objective stems from the need to protect clients from continuing exposure to treatments that are ineffective or potentially harmful due to the ideological biases or financial interests of the service provider (White & Popovits, 2001).
Tempering this argument for AD is another ethical mandate: to not clinically abandon clients to whom one has pledged loyalty and availability. These five objectives provide the primary rationalization underlying the majority of administrative discharges. These objectives make the act of administratively discharging the non-compliant client seem common sense, necessary and even noble.
However, no program of qualitative or empirical research has been conducted to assess the validity of these objectives. The case against administrative discharges As noted, little research has been conducted to test the assumptions upon which current AD arguments rest, but numerous treatment agencies around the country are beginning to re-evaluate their AD practices.
There are seven emerging arguments for stopping or significantly reducing the scope of client behaviors that can result in AD from addiction treatment and for developing programmatic responses that better benefit the client.
Argument #1. Administratively discharging clients from addiction treatment for AOD use is illogical and unprecedented in the health care system. A client is admitted to addiction treatment on the grounds that he or she has a chronic condition, the essence of which is the inability to abstain from or willfully limit their intake of psychoactive drugs in spite of escalating problems related to such use.
Significantly, the just-admitted client is told that AOD use is a violation of program rules and grounds for his or her termination from treatment. The client then consumes alcohol or other drugs in spite of the promised consequence-confirming the grounds upon which their diagnosis was made and their need for professional assistance. As a result of manifesting the primary symptom of the disorder for which the client was admitted to treatment, he or she is expelled from treatment.
We know of no other major health problem for which one is admitted for treatment and then thrown out for becoming symptomatic in the service setting. For other chronic health care problems, symptom manifestation serves as a confirmation of diagnosis or feedback that alternative methods of treatment and alternative approaches to patient education and motivation are needed. In marked contrast, symptom manifestation in the addictions field is grounds for expulsion from service.
Administratively discharging clients from treatment for alcohol or other drug (AOD) use is hypocritical and contradicts the very messages communicated by treatment center personnel to the larger community.
The messages outward are that:
• The client is not in control of their alcohol and/or drug intake or its consequences. • The client needs professional treatment to reacquire such control.
• Reacquisition of control over AOD use/nonuse decisions takes time and may be preceded by one or more episodes of relapse.
• Long-term recovery is best supported by patience and support rather than punishment and abandonment.
Current administrative discharge practices in addiction treatment contradict these messages. We would hope that the days are numbered in which the addictions field can argue that addiction is a primary health care problem while its clinicians continue to treat the primary symptoms of addiction as bad behavior subject to “disciplinary discharge.”
Expelling a client from addiction treatment for AOD use — a process that often involves thrusting the client back into drug-saturated social environments without provision for alternate care — makes as little sense as suspending adolescents from high school as a punishment for truancy.
The strategy should not be to destroy the last connecting tissue between the client and pro-recovery social networks, but to further disengage the client from the culture of addiction and to work through the physiological, emotional, behavioral and characterological obstacles to recovery initiation, engagement, and maintenance.
People with AOD problems should be afforded the same continuity of service contact that those with other chronic health and behavioral health problems are afforded (White, et al., 2003). Argument #2. Administratively discharging clients from treatment for AOD use reflects a fundamental misunderstanding of the role of volition in addiction and recovery.
The very essence of addiction is a progressive deterioration of the will — the erosion of volitional power to not use alcohol or other drugs or to regulate or stop such use once it is initiated. Volitional control over AOD use decisions should be viewed as a desired outcome of addiction treatment, not a required ticket of admission to treatment.
If an individual could consistently exert such control, he or she would, by definition, not need addiction treatment. For those addicted and those recovering from addiction, free will exists, not as a dichotomous state, but in degrees of lost and reacquired power to maintain congruence between intent and actions.
Treatment and sustained recovery involve a progressive rehabilitation of the will. Accountability for AOD use decisions makes sense only to the extent one has reacquired the power to consistently assert one’s choice over such decisions.
Continued in It's Time to Stop Kicking People Out of Addiction Treatment (PDF 151K)
Originally published in Counselor Vol. 6 No. 2 April 2005.
Administrative discharge patterns
A review of the addiction treatment literature reveals a number of key findings related to current administrative discharge practices.
Definitional Problems: Discharge categories and their definitions differ across programs, but there is evidence that discharge rates by type of discharge vary across community-based and prison-based treatment programs (Pelissier, et al., 2003) and vary from therapist to therapist within the same treatment program (Najavits & Weiss, 1994).
Discharge Status and Clinical Outcomes: In adult populations, addiction treatment retention and completion are predictive of positive outcomes, and failure to complete treatment (including those administratively discharged) is predictive of worse outcomes (Price, 1997; Grella, et al., 1999;Wallace & Weeks, 2004).
The role of discharge status on adolescent treatment outcomes is less clear, with one study noting superior outcomes for successful completers (Winters, et al., 2000), and one study noting no significant differences between treatment completers and non-completers (Godley, et al., 2001).
Administrative Discharge Profiles: Adult and adolescent noncompleters are more likely to have clinical profiles marked by younger age, greater problem severity (although some studies report a positive link between severity and retention) psychiatric impairment (i.e., depression, conduct disorder, antisocial personality disorder, schizophrenia), history of perpetration of violence, less motivation for recovery, and less recovery supports in their family and social network (Godley, et al., 2001; Hser, et al., 1998; DeLeon & Jainchill, 1986; Agosti, et al.,1996; DeLeon, et al., 2000; Pelissier, et al., 2003).
Administrative Discharge Prevalence and Level of Care Patterns: At the present time, 18 percent (288,000 thousand) of the 1.6 million people admitted to publicly funded addiction treatment in the United States are administratively discharged (compared to 49 percent who complete treatment, 24 percent who leave against staff advice; and 9 percent who are transferred) (Substance Abuse and Mental Health Services Administration, 2002).
Rates of AD are not uniform across levels of care. The highest to lowest rates of AD are found in methadone maintenance (30.7 percent), long-term residential (24.8 percent), outpatient (23.7 percent), intensive outpatient (19.8 percent), detoxification (9.4 percent), short-term residential (9 percent), and inpatient hospital treatment (4.6 percent) (SAMHSA, 2002).
Common objectives for the use of administrative discharges In reviewing the literature and interviewing colleagues around the country about AD practices, we found five primary objectives that treatment professionals hope to achieve through the use of administrative discharge:
Objective #1: To protect the integrity of the treatment milieu. Administrative discharges are used to prevent and respond to disruptive behaviors that negatively impact the treatment environment. In this view, individuals who are acting out are sacrificed for the greater good of other clients. Many readers would concur that therapeutic milieu is a crucial but fragile dimension of addiction treatment that can be compromised or lost. The AD stands as the ultimate instrument for preserving that milieu, even if applied in an inconsistent manner.
Objective #2: To assure the best utilization of limited treatment resource. Administrative discharges are used to ration addiction treatment services to those who the treatment provider believes can most benefit from it. The AD practice assumes that programs have limited resources and clients who act out are wasting resources that more deserving others could be using. This objective is also met in some programs by discharging clients who cannot pay service fees on the grounds that the long-term financial integrity of the service organization takes precedence over the immediate needs of the non-paying client.
Objective #3: To protect the reputation of the treatment program. Administrative discharges are used to terminate services for clients who continue to use substances or exhibit other disruptive behaviors within the context of treatment. The assumption underlying such extrusion is that allowing clients to continue treatment while using would lead to a loss of community respect and support for the program.
Rumors circulating within the using community regarding toleration of substance use during treatment could also damage the reputation of the program in the eyes of its most important constituents, including more compliant clients.
Objective #4: To prevent the treatment organization and its staff from enabling clients. Programs that use AD to achieve this goal assume that anything short of severing the service relationship with the AOD-using client would, by protecting the client from the consequences of his or her actions, constitute a form of professional enabling. In this view, there is therapeutic harm for continuing to treat the AOD-using client and therapeutic benefit (a motivational “wake-up call”) resulting from treatment expulsion. Clients returning to treatment following AD who contritely confess that they weren’t ready for treatment and that they needed a dose of reality add anecdotal support for this argument.
Objective #5: To fulfill the ethical obligation of terminating and (at least nominally) referring clients who fail to respond to program services. The assumption guiding this objective stems from the need to protect clients from continuing exposure to treatments that are ineffective or potentially harmful due to the ideological biases or financial interests of the service provider (White & Popovits, 2001).
Tempering this argument for AD is another ethical mandate: to not clinically abandon clients to whom one has pledged loyalty and availability. These five objectives provide the primary rationalization underlying the majority of administrative discharges. These objectives make the act of administratively discharging the non-compliant client seem common sense, necessary and even noble.
However, no program of qualitative or empirical research has been conducted to assess the validity of these objectives. The case against administrative discharges As noted, little research has been conducted to test the assumptions upon which current AD arguments rest, but numerous treatment agencies around the country are beginning to re-evaluate their AD practices.
There are seven emerging arguments for stopping or significantly reducing the scope of client behaviors that can result in AD from addiction treatment and for developing programmatic responses that better benefit the client.
Argument #1. Administratively discharging clients from addiction treatment for AOD use is illogical and unprecedented in the health care system. A client is admitted to addiction treatment on the grounds that he or she has a chronic condition, the essence of which is the inability to abstain from or willfully limit their intake of psychoactive drugs in spite of escalating problems related to such use.
Significantly, the just-admitted client is told that AOD use is a violation of program rules and grounds for his or her termination from treatment. The client then consumes alcohol or other drugs in spite of the promised consequence-confirming the grounds upon which their diagnosis was made and their need for professional assistance. As a result of manifesting the primary symptom of the disorder for which the client was admitted to treatment, he or she is expelled from treatment.
We know of no other major health problem for which one is admitted for treatment and then thrown out for becoming symptomatic in the service setting. For other chronic health care problems, symptom manifestation serves as a confirmation of diagnosis or feedback that alternative methods of treatment and alternative approaches to patient education and motivation are needed. In marked contrast, symptom manifestation in the addictions field is grounds for expulsion from service.
Administratively discharging clients from treatment for alcohol or other drug (AOD) use is hypocritical and contradicts the very messages communicated by treatment center personnel to the larger community.
The messages outward are that:
• The client is not in control of their alcohol and/or drug intake or its consequences. • The client needs professional treatment to reacquire such control.
• Reacquisition of control over AOD use/nonuse decisions takes time and may be preceded by one or more episodes of relapse.
• Long-term recovery is best supported by patience and support rather than punishment and abandonment.
Current administrative discharge practices in addiction treatment contradict these messages. We would hope that the days are numbered in which the addictions field can argue that addiction is a primary health care problem while its clinicians continue to treat the primary symptoms of addiction as bad behavior subject to “disciplinary discharge.”
Expelling a client from addiction treatment for AOD use — a process that often involves thrusting the client back into drug-saturated social environments without provision for alternate care — makes as little sense as suspending adolescents from high school as a punishment for truancy.
The strategy should not be to destroy the last connecting tissue between the client and pro-recovery social networks, but to further disengage the client from the culture of addiction and to work through the physiological, emotional, behavioral and characterological obstacles to recovery initiation, engagement, and maintenance.
People with AOD problems should be afforded the same continuity of service contact that those with other chronic health and behavioral health problems are afforded (White, et al., 2003). Argument #2. Administratively discharging clients from treatment for AOD use reflects a fundamental misunderstanding of the role of volition in addiction and recovery.
The very essence of addiction is a progressive deterioration of the will — the erosion of volitional power to not use alcohol or other drugs or to regulate or stop such use once it is initiated. Volitional control over AOD use decisions should be viewed as a desired outcome of addiction treatment, not a required ticket of admission to treatment.
If an individual could consistently exert such control, he or she would, by definition, not need addiction treatment. For those addicted and those recovering from addiction, free will exists, not as a dichotomous state, but in degrees of lost and reacquired power to maintain congruence between intent and actions.
Treatment and sustained recovery involve a progressive rehabilitation of the will. Accountability for AOD use decisions makes sense only to the extent one has reacquired the power to consistently assert one’s choice over such decisions.
Continued in It's Time to Stop Kicking People Out of Addiction Treatment (PDF 151K)