Orlando Rosu
In 2005, my colleagues Christy Scott, Michael Dennis, Michael Boyle, and I co-authored an article entitled It's Time to Stop Kicking People out of Addiction Treatment. At that time, 18% (or 288,000) of people admitted to specialized addiction treatment in the U.S. were administratively discharged ("kicked out") prior to treatment completion. Such expulsions most often resulted from alcohol or other drug use, violation of program rules (e.g., missed appointments, refusal to follow staff directives, fraternization with other patients, etc.), or failure to pay service fees. We drew the following conclusions in the 2005 review.
- Administratively discharging clients from addiction treatment for AOD use is illogical and unprecedented in the health care system.
- Administratively discharging clients from treatment for AOD use reflects a fundamental misunderstanding of the role of volition in addiction and recovery.
- Administrative discharge casts the role of the treatment agency as one of persecutor, and misjudges the meaning and consequences of administrative discharge (AD) to the client.
- Administratively discharging clients from treatment for rule violations is often the endgame in a process of escalating negative countertransference.
- Administratively discharging clients often involves behaviors that are unrelated to, or have only a weak connection to, the prospects or processes of recovery or safety issues within the treatment milieu.
- Administratively discharging clients from treatment casts the blame for treatment failure on the client and prevents treatment programs from evaluating and refining clinical practices.
- Administratively discharging clients from a publicly funded addiction treatment program for failure to pay service fees constitutes clinical abandonment and is a breach of professional ethical principles and (potentially) legal and regulatory standards.
We then outlined 12 policy alternatives to administrative discharge and 6 clinical strategies to reduce such premature treatment discharges.
The 2004 paper contended that 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, we suggested, should not be to destroy the last connecting tissue between the individual and pro-recovery social networks, but to further disengage the person from the culture of addiction and to work through the physiological, emotional, behavioral, and characterological obstacles to recovery initiation and recovery maintenance.
The 2004 paper was followed by blogs in 2014 and 2015 (See HERE and HERE) that updated AD data and added to these early suggestions. New data at that time suggested that AD decisions inordinately target African Americans and persons of low socioeconomic standing, as well as those persons in greatest need of treatment--those with highest problem severity, complexity, and chronicity, and the lowest recovery capital.
The present blog draws on three additional studies, a study of premature treatment termination in an inpatient addiction treatment unit, a study of discharges forbehavioral transgressions among patients in methadone treatment, and a paper addressing AD for patient fraternization.
A just-published (2020) study by Syan and colleagues explored the characteristics of patients who failed to complete residential addiction treatment. Those failing to complete treatment via AD or leaving against medical advice were distinguished by high severity of illicit drug use and high psychiatric severity (particularly PTSD). This study confirmed anew that those most likely to experience a premature termination of treatment are precisely those in greatest need of such treatment. Syan and colleagues called for assertive efforts to identify and offer specialized support for those at highest risk of premature treatment termination.
A recent (2019) study by David Potik and colleagues explored the prevalence of psychopathy among methadone maintenance patients exhibiting continued drug use and other behavioral transgressions (e.g., verbal/physical aggression, selling drugs to other patients, failure to return empty take home medicine bottles, etc.) during the course of their treatment. Both drug use and other behavioral transgressions during treatment were associated with high psychopathy scores.
This study confirmed two important findings. First, as in the Syan study, continued drug use and behavioral transgressions in addiction treatment are often indicators of high addiction severity and co-occurring psychiatric disorders (including personality disorders). Second, evidence suggests it is possible to address these issues within the context of treatment over an extended course of treatment without patient drop out or administrative discharge from treatment.
In light of this study, administratively discharging an MMT patient for drug use and behavioral transgressions may involve punishing the patient for exhibiting symptoms of the very disorders for which treatment is indicated. For other chronic health care problems, symptom manifestation during treatment confirms or disconfirms the working diagnosis and provides feedback on the degree of effectiveness of the treatment methods. In marked contrast, symptom manifestation in the addictions field too often results in blaming and expelling the patient. It is contradictory to argue that addiction (with or without co-occurring psychiatric illness) is a primary health care problem involving loss of volitional control over drug use and its consequences while continuing to treat its primary symptoms as bad behavior warranting termination of the service relationship.
A second study by Hafford-Letchfield and Nelson concludes that the addictions treatment field pathologizes and suppresses sexual desire of patients in ways that go far beyond promoting physical/sexual/emotional safety within the treatment milieu and avoiding romantic/sexual acting out as an escape from the treatment experience. Such pathologization is most evident in bans on patient fraternization and kicking patients out of treatment for becoming romantically involved during their time in treatment.
Patients entering addiction treatment bring all manner of complex sexual histories--histories that may include sexual victimization or predation, sexual dysfunctions, and self-destructive patterns related to past sexual relationships. It is inevitable that these issues rise within milieu-oriented treatment and require clinical attention. Failing to address such issues can lead to concerns related to patient safety, patients using romantic/sexual attraction as a diversion from treatment, or patients leaving treatment prematurely to pursue their relationship. Such concerns are clinical issues to be addressed within the counseling process. But is the expression of sexual desire or mutually (and voluntarily) acting out that desire grounds alone for discharging patients from addiction treatment? Would treatment of any other medical condition be suddenly and prematurely terminated due to sexual involvement between two patients who met within the treatment milieu? Are there no clinical management strategies that would prove more effective in promoting long-term recovery outcomes? Administrative discharges are often characterized as therapeutic discharge, but there is no scientific evidence that kicking a person out of addiction treatment has any positive therapeutic effects.
These new studies point out several shared elements. One, it is the patients who are most in need of treatment and prolonged recovery support that are most likely to be subjected to disciplinary expulsion from addiction treatment. Two, the behaviors most likely to be the justification or expulsion are symptoms of the very problems for which treatment is indicated. In short, too many patients entering addition treatment are arbitrarily discharged for confirming their diagnoses. Third, race, ethnicity, and class interact with problem severity and complexity to predict those patients at greatest risk of expulsion from treatment. Fourth, there are clinical alternatives to management of these behaviors that can enhance long-term recovery outcomes.
We could do much better with these patients and we must.
References
Hafford-Letchfield, T., & Nelson, A. (2008). Closeness equals pathology: Working with issues of sexual desire and intimacy within the substance misuse field. Diversity in Health and Social Care, 5, 215-24.
Potik, D., Abramsohn, Y., Schreiber, S., Adelson, M., & Peles, E. (2019). Drug abuse and behavioral transgressions during methadone maintenance treatment (MMT) are related to high psychopathy levels. Substance Use & Misuse, https://doiorg/10.1080/10826084.2019.1685546.
Syan, S. K., Minhas, M., Oshri, A, Costello, J., et al., (2020) Predictors of premature treatment termination in a large residential addiction medicine program. Journal of Substance Abuse Treatment, 117, 108077.
White, W., Scott, C., Dennis, M. & Boyle, M. (2005) It's time to stop kicking people out of addiction treatment. Counselor, 6(2), 12-25.