Administrative Discharges in Addiction Treatment: Bringing Practice in Line with Ethics and Evidence

Administrative Discharges in Addiction Treatment: Bringing Practice in Line with Ethics and Evidence Social workers who practice within addiction treatment centers are often faced with difficult decisions when attempting to foster and maintain a safe therapeutic milieu for their clients. Establishing clear rules and expectations helps to hold clients accountable to sustaining positive behavior change and to minimize the risk of clients doing harm to peers or staff. One strategy that has been used to enforce such rules is called administrative discharge (AD), when treatment centers expel clients as a consequence for infractions against the rules of the center. This practice of separating vulnerable people from treatment should give social workers pause, if for no other reason than to ensure that they are not violating the National Association of Social Workers (2015) (NASW) Code of Ethics Section 1.16(b) injunction against client abandonment. This article summarizes some of the current thinking on AD and proposes measures that can be taken by treatment facilities to decrease reliance on this practice. In a seminal article on this topic, White, Scott, Dennis, and Boyle (2005) asserted that, when future professionals look back on the current era of addiction treatment, they are likely to view the current practice of AD similarly to the way modern physicians consider treating morphine addiction with cocaine: a method based on incomplete knowledge that ultimately does more harm than good. It is difficult to ascertain what the true effects of AD are on clients, as current claims about the relative harm and benefits of AD rest on an insufficient knowledge base to make any firm conclusions (Williams, 2015, 2016). What is known from the sparse literature published on the topic suggests at least two things: (1) the use of AD in treatment programs is prevalent enough to warrant skeptical inquiry and (2) clients who are administratively discharged feel slighted by their expulsion. In support of the first point, data from the Treatment Episode Data Set show that, nationally, 126,718 clients, or 7.3 percent of total admissions to public addiction treatment centers, were administratively discharged in 2011 (Substance Abuse and Mental Health Services Administration, 2014; Williams, 2015). In terms of the second point, a study of 35 heroin users who had recently been administratively discharged from medication-assisted treatment in Sweden reported that AD was perceived as disingenuous and largely sent participants back into environments where they were susceptible to relapse and decreased quality of life (Svensson & Andersson, 2012). Why Dismiss Clients from Addiction Treatment? Despite negative perceptions in the eyes of clients, there is evidence to suggest that AD enjoys some support among practitioners. In a survey of a sample of 317 counselors, psychiatrists, psychologists, social workers, and other practitioners employed by addiction treatment facilities in the Delaware Valley Clinical Trials Network, Forman, Bovasso, and Woody (2001) found that 36 percent agreed with the statement: “Noncompliant patients should be discharged.” This discrepancy between providers and those they care for is striking. Certainly, most addiction treatment professionals want the best for their clients and would prefer that each client be successful in completing the course of treatment. Rather than maleficence, it is more likely that practitioner adherence to AD stems from unexamined (and untested) beliefs about the recovery process. White et al. (2005) provided a list of prominent reasons that treatment centers give for practicing AD—all of which stem from beliefs that it will help the client, the treatment center, or both (for further reading on the arguments made in favor of AD, see Williams & Taleff [2015]). In the absence of evidence-informed protocols to govern when AD is appropriate, frontline staffs must make precarious decisions, at times, without proper oversight. This is especially true in the case of administratively discharging a client who has relapsed while in treatment. Such uses of AD are special cases of inconsistency between an understanding of addiction as a disease and the practices used in treatment settings. It is problematic for the treatment community to argue the position that addiction is a chronic, relapsing brain disorder while simultaneously condoning practices that expel clients from treatment when their only offense is exhibiting the very behaviors characteristic of that disorder (White et al., 2005). However, the intent of this article is not to communicate that there is never an ethically justifiable reason to administratively discharge a client. Although there may not yet be adequate research evidence to support the use of AD, the social work field has the means to evaluate the practice in light of its code of ethics. One of the responsibilities of practitioners is to enforce a certain standard of behavior from clients. It is a good and therapeutic thing to establish prosocial behavioral norms in treatment settings, and disciplinary measures are often required to maintain them. Moreover, some behaviors constitute such a level of transgression against these norms and the safety and wellness of relevant parties that they warrant removing a client from the environment. However, the standard used to evaluate when to use such measures remains unclear and is likely being inconsistently applied around the nation. The following section outlines a strategy for responding to client misbehavior in such a way that AD is only used in instances where it is appropriate. Recommendations First, treatment centers should form clear, transparent policies about what standard of behavior is expected from clients as a condition of participation in the program. If a treatment center chooses to use AD, clients should be made aware of what offenses would cause that center to expel them before they are formally admitted to the program. As a means of tailoring corrective action to the proportionate severity of rule violations, it would be fitting for centers to categorize offenses. In Figure 1, A, B, and C are used as category names, but these offenses can be categorized in any way deemed appropriate by treatment center authorities. In terms of AD, centers could determine which infractions are unacceptable and warrant dismissal (for example, assaulting another client) versus those that need minor remediation, such as habitual tardiness. It is beyond the scope of this article to prescribe a detailed outline of how to categorize every foreseeable offense, but the fundamental framework of assessing the severity of the charge and basing the response on a predetermined disciplinary protocol could serve to prevent some of the more frivolous uses of AD. I recommend that treatment facilities also create corrective action measures for category B and category C offenses to more properly align their policies with the understanding of addiction that acknowledges the struggles that clients will inevitably face (see Figure 1). Figure 1: View largeDownload slide Administrative Discharge Decision Tree Figure 1: View largeDownload slide Administrative Discharge Decision Tree Once policies are in place, another measure that can be implemented to ensure that clients are not discharged inappropriately is to form AD panels. These panels could consist of frontline treatment staff who are familiar with the client in question as well as supervisors or administrators who can provide oversight and perspective to the process of deliberation. Whenever an infraction has occurred, it would be wise to convene such a panel as a means of allowing heads to cool and call on the collective wisdom of a group. With their collective effort, the group could assess the situation, place the client’s offense properly within the category system, and determine the best way to respond. Furthermore, I have offered a justification for ethically permissible AD in each of the category violations. As stated earlier, category A violations are those that a treatment center has deemed so severe that even one commission warrants expulsion from the program. Examples of these types of offenses would likely be serious criminal behavior such as physically assaulting a peer client or bringing a weapon into the treatment center. The ethical justification for using AD after a category A offense would be to protect the health and safety of clients and enforce the maintenance of a safe treatment environment. Category B and category C violations are less severe than category A offenses and should be treated with more nuance. I have illustrated in Figure 1 that these violations should not warrant AD the first time a client commits them, as they may be mere maladaptive behaviors that can be addressed through other means. Examples of a category B violation might include threatening violence toward another client or a staff person. Such an action should be taken seriously, but not all such threats should warrant expulsion. However, if the same client threatens the same person in the same way more than once, the AD panel may deem that there is sufficient risk for escalation toward the commission of a category A violation and that an AD is warranted as a preventive measure. Category C violations would be offenses that are relatively benign, for example, tardiness for treatment programming such as group therapy sessions. These violations do not seriously endanger anyone or threaten the integrity of the treatment milieu, but are disruptions in the smooth execution of providing services. Although individual instances of category C violations should be addressed with corrective measures, repeated and habitual occurrences may be an indication of a poor match between the treatment modality and the client. Figure 1 does illustrate the possibility for category C violations to become so disruptive that an AD is warranted, but, in such cases, social workers should consider referring clients to an alternate treatment modality or a higher level of care rather than merely expelling them from the program. Conclusion The decision to expel a client from addiction services before the client has reaped the full benefit from treatment is a difficult one, and one that is currently too loosely practiced in the United States. When social workers are involved in the treatment of clients who struggle with addiction, they must acknowledge that clients will often exhibit inappropriate behavior and a tendency toward relapse. Although some extreme instances of client misbehavior may warrant an AD, it is important for social workers not to resort to such an extreme measure without a thorough assessment of the situation. These assessments should be consistent with our professional code of ethics and a current scientific understanding of addiction. References Forman, R. F., Bovasso, G., & Woody, G. ( 2001). Staff beliefs about addiction treatment. Journal of Substance Abuse Treatment,  21( 1), 1– 9. Google Scholar CrossRef Search ADS   National Association of Social Workers. ( 2015). Code of ethics of the National Association of Social Workers . Washington, DC: Author. Substance Abuse and Mental Health Services Administration. ( 2014). Treatment episode data set (TEDS): 2011: Discharges from substance abuse treatment services  (BHSIS Series S-70, HHS Publication No. [SMA] 14-4846). Rockville, MD: Author. Svensson, B., & Andersson, M. ( 2012). Involuntary discharge from medication-assisted treatment for people with heroin addiction: Patients’ experiences and interpretations. Nordic Studies on Alcohol and Drugs,  29( 2), 173– 193. Google Scholar CrossRef Search ADS   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. Williams, I. ( 2015). Is administrative discharge an archaic or synchronic program practice? The empirical side of the debate. Online Journal of Health Ethics,  11( 2), Article 6. Williams, I. L. ( 2016). Moving clinical deliberations on administrative discharge in drug addiction treatment beyond moral rhetoric to empirical ethics. Journal of Clinical Ethics,  27, 71– 75. Williams, I. L., & Taleff, M. J. ( 2015). Key arguments in unilateral termination from addiction programs: A discourse on ethical issues, clinical reasoning, and moral judgments. Journal of Ethics in Mental Health,  9, 1– 9. © 2017 National Association of Social Workers http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Social Work Oxford University Press

Administrative Discharges in Addiction Treatment: Bringing Practice in Line with Ethics and Evidence

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Oxford University Press
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© 2017 National Association of Social Workers
ISSN
0037-8046
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1545-6846
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10.1093/sw/swx054
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Abstract

Social workers who practice within addiction treatment centers are often faced with difficult decisions when attempting to foster and maintain a safe therapeutic milieu for their clients. Establishing clear rules and expectations helps to hold clients accountable to sustaining positive behavior change and to minimize the risk of clients doing harm to peers or staff. One strategy that has been used to enforce such rules is called administrative discharge (AD), when treatment centers expel clients as a consequence for infractions against the rules of the center. This practice of separating vulnerable people from treatment should give social workers pause, if for no other reason than to ensure that they are not violating the National Association of Social Workers (2015) (NASW) Code of Ethics Section 1.16(b) injunction against client abandonment. This article summarizes some of the current thinking on AD and proposes measures that can be taken by treatment facilities to decrease reliance on this practice. In a seminal article on this topic, White, Scott, Dennis, and Boyle (2005) asserted that, when future professionals look back on the current era of addiction treatment, they are likely to view the current practice of AD similarly to the way modern physicians consider treating morphine addiction with cocaine: a method based on incomplete knowledge that ultimately does more harm than good. It is difficult to ascertain what the true effects of AD are on clients, as current claims about the relative harm and benefits of AD rest on an insufficient knowledge base to make any firm conclusions (Williams, 2015, 2016). What is known from the sparse literature published on the topic suggests at least two things: (1) the use of AD in treatment programs is prevalent enough to warrant skeptical inquiry and (2) clients who are administratively discharged feel slighted by their expulsion. In support of the first point, data from the Treatment Episode Data Set show that, nationally, 126,718 clients, or 7.3 percent of total admissions to public addiction treatment centers, were administratively discharged in 2011 (Substance Abuse and Mental Health Services Administration, 2014; Williams, 2015). In terms of the second point, a study of 35 heroin users who had recently been administratively discharged from medication-assisted treatment in Sweden reported that AD was perceived as disingenuous and largely sent participants back into environments where they were susceptible to relapse and decreased quality of life (Svensson & Andersson, 2012). Why Dismiss Clients from Addiction Treatment? Despite negative perceptions in the eyes of clients, there is evidence to suggest that AD enjoys some support among practitioners. In a survey of a sample of 317 counselors, psychiatrists, psychologists, social workers, and other practitioners employed by addiction treatment facilities in the Delaware Valley Clinical Trials Network, Forman, Bovasso, and Woody (2001) found that 36 percent agreed with the statement: “Noncompliant patients should be discharged.” This discrepancy between providers and those they care for is striking. Certainly, most addiction treatment professionals want the best for their clients and would prefer that each client be successful in completing the course of treatment. Rather than maleficence, it is more likely that practitioner adherence to AD stems from unexamined (and untested) beliefs about the recovery process. White et al. (2005) provided a list of prominent reasons that treatment centers give for practicing AD—all of which stem from beliefs that it will help the client, the treatment center, or both (for further reading on the arguments made in favor of AD, see Williams & Taleff [2015]). In the absence of evidence-informed protocols to govern when AD is appropriate, frontline staffs must make precarious decisions, at times, without proper oversight. This is especially true in the case of administratively discharging a client who has relapsed while in treatment. Such uses of AD are special cases of inconsistency between an understanding of addiction as a disease and the practices used in treatment settings. It is problematic for the treatment community to argue the position that addiction is a chronic, relapsing brain disorder while simultaneously condoning practices that expel clients from treatment when their only offense is exhibiting the very behaviors characteristic of that disorder (White et al., 2005). However, the intent of this article is not to communicate that there is never an ethically justifiable reason to administratively discharge a client. Although there may not yet be adequate research evidence to support the use of AD, the social work field has the means to evaluate the practice in light of its code of ethics. One of the responsibilities of practitioners is to enforce a certain standard of behavior from clients. It is a good and therapeutic thing to establish prosocial behavioral norms in treatment settings, and disciplinary measures are often required to maintain them. Moreover, some behaviors constitute such a level of transgression against these norms and the safety and wellness of relevant parties that they warrant removing a client from the environment. However, the standard used to evaluate when to use such measures remains unclear and is likely being inconsistently applied around the nation. The following section outlines a strategy for responding to client misbehavior in such a way that AD is only used in instances where it is appropriate. Recommendations First, treatment centers should form clear, transparent policies about what standard of behavior is expected from clients as a condition of participation in the program. If a treatment center chooses to use AD, clients should be made aware of what offenses would cause that center to expel them before they are formally admitted to the program. As a means of tailoring corrective action to the proportionate severity of rule violations, it would be fitting for centers to categorize offenses. In Figure 1, A, B, and C are used as category names, but these offenses can be categorized in any way deemed appropriate by treatment center authorities. In terms of AD, centers could determine which infractions are unacceptable and warrant dismissal (for example, assaulting another client) versus those that need minor remediation, such as habitual tardiness. It is beyond the scope of this article to prescribe a detailed outline of how to categorize every foreseeable offense, but the fundamental framework of assessing the severity of the charge and basing the response on a predetermined disciplinary protocol could serve to prevent some of the more frivolous uses of AD. I recommend that treatment facilities also create corrective action measures for category B and category C offenses to more properly align their policies with the understanding of addiction that acknowledges the struggles that clients will inevitably face (see Figure 1). Figure 1: View largeDownload slide Administrative Discharge Decision Tree Figure 1: View largeDownload slide Administrative Discharge Decision Tree Once policies are in place, another measure that can be implemented to ensure that clients are not discharged inappropriately is to form AD panels. These panels could consist of frontline treatment staff who are familiar with the client in question as well as supervisors or administrators who can provide oversight and perspective to the process of deliberation. Whenever an infraction has occurred, it would be wise to convene such a panel as a means of allowing heads to cool and call on the collective wisdom of a group. With their collective effort, the group could assess the situation, place the client’s offense properly within the category system, and determine the best way to respond. Furthermore, I have offered a justification for ethically permissible AD in each of the category violations. As stated earlier, category A violations are those that a treatment center has deemed so severe that even one commission warrants expulsion from the program. Examples of these types of offenses would likely be serious criminal behavior such as physically assaulting a peer client or bringing a weapon into the treatment center. The ethical justification for using AD after a category A offense would be to protect the health and safety of clients and enforce the maintenance of a safe treatment environment. Category B and category C violations are less severe than category A offenses and should be treated with more nuance. I have illustrated in Figure 1 that these violations should not warrant AD the first time a client commits them, as they may be mere maladaptive behaviors that can be addressed through other means. Examples of a category B violation might include threatening violence toward another client or a staff person. Such an action should be taken seriously, but not all such threats should warrant expulsion. However, if the same client threatens the same person in the same way more than once, the AD panel may deem that there is sufficient risk for escalation toward the commission of a category A violation and that an AD is warranted as a preventive measure. Category C violations would be offenses that are relatively benign, for example, tardiness for treatment programming such as group therapy sessions. These violations do not seriously endanger anyone or threaten the integrity of the treatment milieu, but are disruptions in the smooth execution of providing services. Although individual instances of category C violations should be addressed with corrective measures, repeated and habitual occurrences may be an indication of a poor match between the treatment modality and the client. Figure 1 does illustrate the possibility for category C violations to become so disruptive that an AD is warranted, but, in such cases, social workers should consider referring clients to an alternate treatment modality or a higher level of care rather than merely expelling them from the program. Conclusion The decision to expel a client from addiction services before the client has reaped the full benefit from treatment is a difficult one, and one that is currently too loosely practiced in the United States. When social workers are involved in the treatment of clients who struggle with addiction, they must acknowledge that clients will often exhibit inappropriate behavior and a tendency toward relapse. Although some extreme instances of client misbehavior may warrant an AD, it is important for social workers not to resort to such an extreme measure without a thorough assessment of the situation. These assessments should be consistent with our professional code of ethics and a current scientific understanding of addiction. References Forman, R. F., Bovasso, G., & Woody, G. ( 2001). Staff beliefs about addiction treatment. Journal of Substance Abuse Treatment,  21( 1), 1– 9. Google Scholar CrossRef Search ADS   National Association of Social Workers. ( 2015). Code of ethics of the National Association of Social Workers . Washington, DC: Author. Substance Abuse and Mental Health Services Administration. ( 2014). Treatment episode data set (TEDS): 2011: Discharges from substance abuse treatment services  (BHSIS Series S-70, HHS Publication No. [SMA] 14-4846). Rockville, MD: Author. Svensson, B., & Andersson, M. ( 2012). Involuntary discharge from medication-assisted treatment for people with heroin addiction: Patients’ experiences and interpretations. Nordic Studies on Alcohol and Drugs,  29( 2), 173– 193. Google Scholar CrossRef Search ADS   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. Williams, I. ( 2015). Is administrative discharge an archaic or synchronic program practice? The empirical side of the debate. Online Journal of Health Ethics,  11( 2), Article 6. Williams, I. L. ( 2016). Moving clinical deliberations on administrative discharge in drug addiction treatment beyond moral rhetoric to empirical ethics. Journal of Clinical Ethics,  27, 71– 75. Williams, I. L., & Taleff, M. J. ( 2015). Key arguments in unilateral termination from addiction programs: A discourse on ethical issues, clinical reasoning, and moral judgments. Journal of Ethics in Mental Health,  9, 1– 9. © 2017 National Association of Social Workers

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Social WorkOxford University Press

Published: Jan 1, 2018

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