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Patients dangerously see completion of residential care as the end

June 25, 2018
by Michael Weiner, PhD, MCAP
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I would like to devote this blog to anything having to do with treating a chronic disease as a chronic disease needs to be treated, and the steps we can take as professionals to eliminate the stigma that we blame on the culture at large.

That being said, I was recently waiting for a meeting to begin in one of the nation's finest treatment centers. There was a man sitting close by chatting with a person who worked at the facility. It sounded to me like the man had worked very hard on his recovery from the very first day he walked in the door. What caught my ear was the comment “I'm in the home stretch.” It was fairly obvious that this person perceived himself to be completing treatment.

Who can blame him? That's the way most people perceive treatment for substance use disorders.

I suspect this person had a very solid continuing care plan. However, that's not perceived as treatment. When a person uses the phrase “I'm going to treatment,” most people understand it to be residential care.

Words such as “aftercare” persist. That clearly connotes “afterthought,” something not terribly important.

Yet research is telling us that when treatment is perceived to include every level of care, patients do remarkably well. What do we need to do?



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Thank you Dr. Weiner for highlighting our industry's need to change the patients' and their families' expectations on what they are "buying" when they enter a residential treatment program. The 28 day model of come in, get clean, and go out into your life refreshed and renewed is a fantasy that has been sold by treatment providers more interested in putting 'heads in beds' rather than providing quality care that reflects the reality of the disease. Patients and their loved ones need to know that residential treatment is simply the beginning of a life long trek through challenging terrain.

Thank you Paul. 

I'm reminded of the times when people have approached me and asked, "what are your outcomes?" They are essentially asking me what percentage of your patients are abstinent for some period of time following treatment.

It occurs to me that people don't ask that question to professionals treating other chronic diseases, diabetes for example. I think that's because diabetics are perceived to remain in treatment. Periods of intability are OK because ongoing treament will lead to improvement.

People with adiction do not have te same luxury.People with addiction are perceived to have completed treatment. Symptoms becoming active, e. g. drinking, indicate that treatment has failed.

Who ever came up with such a system of masurement?


Unfortunately insurance add to the perception that addiction and mental health issues can be "cured" in a month or two.They often expect me as a psychologist to get someone to complete treatment in 8 to 10 sessions. I have to justify why I need more sessions to treat someone with a cocaine addiction and years of childhood trauma. They also do not recognize how therapy can help maintain functioning and ask you to discharge the patient if there is no "improvement". Then months later the patient is in crisis and/or relapses and needs 20 thousand dollars of inpatient treatment again. It makes no sense and ends up costing the insurance company more.

Janelle57; Thank you for your comment. It is frustrating. However, it's important that we keep advocating. There are a number of people advocating for, essentially, a chronic care model. I believe that Dr Roland Reeves (hope spelling is correct, see his blog) at Destin Recovery Center in Florida is advocating for a similar approach. There's also people like Drs David Mee-Lee & Michael Boticelli. Bill White has been among the most prolific advocates.

Soon or later insurance companies will figure out that we can help them save money.

It's our responsibility to advocate for the highest quality of care.

Does it make a difference if treating addiction is perceived to be a series of acute episodes as opposed to applying a recovery management model? I want to suggest that you try something:

The next time someone comes up to you and says something like, "I've been to treatment three times," challenge the statment. Suggest to the person that it's been one treatment. Care began when addiction was initially diagnosed and the severity of the symptoms symptoms indicated the need for a high level of care (residential), Suggest the possibility that the residential center may not have provided a very good continuing care plan, or maybe the patient did not follow the plan very well. Maybe the importance of the plan was not conveyed.  

The result was that the symptoms became severe again. The symptoms indicated that a return to residential care was necessary. The bottom line has been that the severity of the symproms always dictates the level of care.

If the symptoms did not reach a very severe level outpatient care could have been recommended. 

It's been one treatment, not a series of failures.  And empasize to staff & to the patient how important an ongoing plan is.  "Aftercare?" Maybe call residential "Beforecare?" The point is that every level of care is equally important.

Watch the patient, watch the shame lift as the feeling of numerous failures goes away. 

If you do try this, I would like to hear about your experience. Please comment..


I've been trying to champion the need for continuous care rather than treatibg acute episodes of a chronic disorder. I have a private practice. There are occasions on which I'm the first person that a new patient talks to about their substance use issues. That's where case management begins. My responsibility at that time is to do a thorough assessment of the patient's disorder and co-occurring issues. A level of care needs to be recommended. In an ideal world the patient would immediately accept the recommendation. The reality is that it might take some work. However, this is where recovery begins. I didn't say "abstinence" I said "recovery." There's a difference.

None of us have difficulty perceiving addiction as a chronic disease. There is resistence to applying a chronic care model to treat it.

Let's say that I've recommended to my patient that withdrawal management is needed at this time. It may also be the time to engage the family.

The point that I'm trying to make here is that over the course of a lifetime the patient and family are going to need a number of services.Treatment will not end with withdrawal management or residential care. Family counseling may be needed or the patient may need to address trauma issues. Medical issues are likely to pop up.

Elsewhere I have argued for "Recovery Check-ups over the course of a lifespan.

A Case Manager is the person that can assure that the best professionals will provide the sercices that are needed.

This is a chronic, lifespan disorder. Over the course of a lifetime Case Managers may change. BUT: the CaseManager will always be the best person to assure the highest quality of care.




Michael Weiner


Michael Weiner

Michael Weiner, Ph.D., MCAP has been engaged in the delivery of care for addiction since 1999....

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