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Caught in the Middle on Program Discharges

January 1, 2006
by root
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I had mixed feelings after reading the article by Nicholas A. Roes, PhD, “Use Program Discharges as Chance to Look Inward,” in the September 2005 issue. As director of all addiction treatment services at Three Rivers Behavioral Health in West Columbia, South Carolina, I do struggle with discharges and appropriate referral. I am also the lead counselor for our intensive outpatient program (IOP) and, with my staff, regularly make judgments on whom to keep in the program and whom to refer. The decisions are never easy and are seldom made on the fly.

As the article recommends, I ask myself what we could have done differently to keep a person in treatment or to better assess him on the front end. I never discharge a difficult client without asking myself, “I wonder if we should have…."

At the same time, the article did sting for those of us on the frontlines. We're a private treatment center, and we pride ourselves on being the best. We employ 12-Step philosophy, Motivational Interviewing, Stages of Change theory, Rational Emotive Behavior Therapy (REBT), family systems counseling, and a host of other approaches to treating addiction. Our medical director is an ASAM-certified psychiatrist. We have twice-weekly family nights and a twice-weekly aftercare group. We provide a family aftercare group as well, at no charge. We're also insurance-based, which means we fight for every 13 or 20 sessions we can squeeze out of the payers.

In our IOP, my staff and I move quickly and efficiently. Unfortunately, this includes quick decisions on whether to keep someone or refer him on for the good of the community and the good of his insurance dollars (which he will likely need in the future). How long do I give an unmotivated person the opportunity to get onboard before sacrificing him for the good of the group? What about the one for whom treatment is “fun and games,” as one of our counselors succinctly puts it? What about the one who is passively “taking up space” to appease a spouse?

What frustrates me is there are often no easy answers to the questions raised in the article. The insurance company insists that we “move 'em on” while others may accuse us of “kicking them out of treatment.” I wish I had the time and staffing to move “difficult” clients into another group to see what we could do with them. I'm sad and angry that I haven't an extra month for an unmotivated client to get motivated.

I do hear and agree with the thesis of the article. Discharges are a call for me to look inward on what I can do better to work with difficult clients and retain them. I just wish I had more help from somewhere in dealing with the concrete realities that I've outlined.

Grateful for our patients, staff, and program, I am

Larry E. Brown, MAC, MDiv, Director, Addiction Treatment Services, Three Rivers Behavioral Health, West Columbia, South Carolina