Inpatient or Outpatient?
The goals of rehabilitation can often be accomplished without necessarily “going away” to an inpatient setting. Structured outpatient treatment programs include education, group bonding, work on more subtle forms of denial, and support in maintaining abstinence. However, since the decision to go to treatment must be made for each session over a period of weeks or months, there must be a greater degree of self-motivation.
Who needs inpatient treatment?
- The simplest criteria for making this decision are as follows:
- Outpatient treatment requires:
- Willingness and ability to attend sessions diligently and regularly.
- The ability to abstain from all mood altering substances for 48 hours at a time with support.
- Those who cannot meet these criteria will probably need to be referred to an inpatient rehabilitation program.
What if the addicted person doesn’t believe he or she has a problem?
- External motivation is OK. Many people start recovery because of a push from someone else.
- All rehab programs are voluntary. (Historically, Rockefeller programs, which were involuntary, were not a success.) Therefore, the patient must still give his or her consent to treatment. This level of acceptance is good enough for the beginning of recovery.
- For adolescents, we feel that the basic training, even if the patient clearly wants to return to drug use as soon as possible following treatment, is still worth a great deal. The education and the experience of what recovery is like may not be utilized immediately, but are likely to be valuable in the future.
What if the addicted person has been in treatment before?
- It is good to get evaluation and advice about this from a professional familiar with recovery. Sometimes the individual is at a new stage of recovery, and the experience will be entirely different than before. At other times, it may be repetitious. Some programs have a specialized “relapse” track, which may be more relevant.
- When we evaluate patients who have relapsed, we look at three areas:
- Was there ever a full recovery program in place?
- Is there a source of enabling that is preventing recovery from working?
- Is there an internal “Stuck Point,” (See Terrance Gorsky’s writings) that stops the recovery process at a certain spot?
What if the problem has significant psychiatric aspects?
- This is a hard question to address in general. Evaluation by a professional who specializes in substance abuse as well as mental health is particularly important. Many mental health specialists are well trained at recognizing symptoms of psychiatric problems, but may not be as knowledgable about how emotional symptoms interact with addiction. Addiction specialists may not be as sensitive to emotional problems and diagnoses. Let’s take anxiety for example:
- Anxiety can be a result of addiction.
- Anxiety can be an accompaniment of addiction.
- Anxiety can be a contributor to addiction.
- If you think the person you are concerned about could be "dual diagnosis,” put your energy into getting the best possible initial evaluation and treatment recommendation.
- Where addiction and other psychiatric problems coexist, the options are either to focus on the addiction first, or both problems at once. It is almost never optimal to focus on emotional problems before focusing on an active addiction.
What kind of program
Freestanding Inpatient Rehabilitation
These programs live by their ability to create a life-changing experience. Many of them do amazing work in the short time they have.
Hospital Based Rehabilitation Unit
The quality depends on the particular unit and hospital. Some insurance policies may only reimburse for a unit that is part of a general hospital. Hospital based rehab units may be more able to work with patients who have complicating psychiatric or physical illness.
Hospital Detoxification Unit
Withdrawal from alcohol and sedative medication is the most dangerous, though opiate withdrawal is extremely intense. Freestanding rehab programs may do detoxification, but the hospital may have more medical backup for complicated or difficult cases. Increasingly, detoxification is being done on an outpatient basis.
Watch out for the problem of the patient who finishes the detoxification feeling better than in years, and is suddenly no longer motivated for treatment. Before entering a unit that does detoxification only, be sure that a very strong route has been established for follow up rehabilitation, either inpatient or outpatient.
Long Term Residential Program
Following rehabilitation, many individuals lack the impulse control and sober habits to successfully maintain a recovery in their community. This is especially true of young people, who have maturational work to do as well as recovery.
For these individuals, long term residential treatment may make the difference between success and failure. Professional staff in rehab programs will help evaluate the need and feasibility of long term residential treatment.
Staff in rehab programs are also a good source of up to date knowledge about the quality and services of long term residential programs.
The term “rehab” usually refers more to programs that are associated with an AA or 12 step tradition. Therapeutic Communities have their origins with Synanon and such programs oriented primarily for heroin abusers. Nowadays, many are much stronger supporters of total abstinence and the 12 step principles. They may encourage and require residential stays of up to 2 years. When the addiction is serious enough to warrant such a long length of stay, these programs may offer an approach that is uniquely effective.
Should you focus on programs exclusively for a special population?
- Special programs for special populations have advantages and disadvantages. Addicted people have a tendency to think that they are “different” from everyone else. That is part of the isolation. If they find themselves in a program that is specialized for just the group they identify with, that “uniqueness” defense may melt away. On the other hand, feeling like a special member of a special group may actually strengthen the sense of being different, and with it a need to pick and choose among recovery tools and supports. Picking and choosing is not good for early recovery.
- Criterion: If membership in a special group is likely to be a real barrier to mainstream treatment, then do try to find a special program of high quality. Otherwise, a mainstream program with people of roughly similar background may be more helpful.
Matching the program to the person
A major part of recovery is “identifying” with other recovering people. Extreme cultural/educational differences may be an impediment to seeing the commonality of addictions. In general, some diversity is useful. It is often surprising who an individual most identifies with, on the other hand, adding culture shock to the stress of rehabilitation is not therapeutic in itself.
Local vs. Long Distance
Many insurance companies emphasize local treatment. One advantage is that family members can more easily participate in the family program. On the other hand, the cost of airfare is a small fraction of the total outlay, and the program’s ability to provide just the services you need may justify travel. Especially for young people, being away from familiar “people places and things,” may be an advantage. Rehab programs away from home may also have ties with long term residential programs in their locale.