Managing Relapse In Treatment – What’s The Best Policy?

spiral_staircaseBy Terence T. Gorski

Should patients be discharged if they have been caught using alcohol or other drugs?

This is a tough question. I see two conflicting values that have t be balanced:

  • The well-being of the individual vs.
  • The well-being of the treatment/ recovery program.

Treatment professionals need to carefully think about this issue and set a policy and procedure after looking at all sides of the issue. Here are some suggestions I have made to treatment programs:

1.         At admission, let patients clearly know that the program is based upon abstinence.

2.         Ask the patient to make a formal statement and sign an agreement documenting their decision to stop using alcohol and other drugs.

3.         Let them know the difference between a relapse (i.e. involuntarily giving in to a craving) and deception (choosing to use and deciding to hide it). Be clear that selling alcohol or drugs is grounds for immediate discharge.

3.         If someone starts to use and they self-report before being caught using, the treatment plan needs to be suspended and an evaluation done to determine the needs of the patients. Something didn’t work in the previous treatment plan if the person is using.

4.         If someone starts to use and hides it, stabilize and evaluate. Have a very high level of suspicion the patient didn’t lose control but got caught. The dishonesty about it is the problem. Once stable, give them a chance to explain what happened and what will be different. The burden is on them to prove they learned something.

5.         If the policy is punitive, especially with patients facing consequences in the real word for returning to use, the patient will have good reason to try to cover the initial lapse. The members of the recovering community in the treatment center will be more likely to protect and enable them.

6.         Make it the responsibility of the community to protect the sober environment. Do it in a way that does not reinforce the jail house mentality of “ratting someone out,” and neither does it set up a “witch hunt mentality.”

7.         Never, ever (did I say never) have the patient community vote on whether the patient stays or leaves. This is a clinical decision that needs to be made by professional staff.

This approach can be summarized as follows:

(1)       Stop business as usual.

(2)       Stabilize and evaluate the relapsed patient.

(3)       Do a comprehensive evaluation that takes into account the individual needs of the patient and the needs of the patient community.

(3)       Honestly involve the patients in the community in open fact-finding, putting the relapsed patient’s needs first until stabilized, and then seeing that a decision flows from an orderly decision-making process and not an emotional knee-jerk reaction.

(4)       If the decision is made for the patient to stay, the patient needs to present and analysis of the relapse warning signs that led up to the chemical use, the lessons learned in terms of what they can do differently if these warning start showing up again, and what is their new plan to recognize and manage the warning signs and work on the issues that trigger obsession, compulsion, drug seeking behavior, and use.

(5)       It is also important to openly talk about who knew this patient was in trouble before they used or was using but hid it from the staff and patient community. This should lead into a discussion of enabling. Each patient should discuss how they want the community to deal with them if they are showing warning signs or if someone in the community thinks they have started using.

A WORD ABOUT ALCOHOL AND DRUG TESTING

I find testing to be of limited value. Usually the staff suspects the person is in trouble with their recovery or has started using. This is what motivated them to have the patient tested. If the staff can’t notice the different response in patients who are abstinent and working at their recovery, and those who are using alcohol and other drugs, something is very wrong., It would be a priority to evaluate why the staff can’t develop close enough relationships with the patients to notice.

HAVING A POLICY brings all of these difficult ideas out into the daylight. This is a very important area that many professional are reluctant to discuss. There are no right or wrong policies in this regard. The policy is either well thought out, puts the needs of both the relapsed patient and the community as important concerns, stabilizes and assesses the relapsed patient, and develops a plan based on what the assessment reveals..

It to be the highest integrity and most consistent option to recognize the chemical use immediately, suspend the existing treatment plan (it’s obviously not working anyway), and then stabilize the patient and do an extensive guided self-assessment of what happened and what should be done.

RECOGNIZE –> INTERVENE –> STABILIZE –> ASSESS –> NEW PLAN 

 “I would say it is unethical to discharge a patient for being symptomatic of their disease. This is client abandonment, and violates the principle of Fidelity. I am pretty sure the state of California is actually going to put this into regulations. 

That doesn’t mean you ignore it and go back to business as usual. If the “common welfare” demands that they be out of the program they I would say you have an ethical obligation to try to place (not just refer) them in another program. Ideally you would have an MOU with other programs and agree to accept each other’s placements in cases like this. Just don’t kick them out with an outdated referral sheet. As professionals we have to consider that we may have failed the client in some way; another reason to not be too rigid.” ~ Fr. Jack Kearney, M.Div., CATC IVBoard Member/Past President at California Association for Alcohol & Drug Educators (CAADE) 

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