Residential treatment programs treating substance use disorders are not locked from the inside — for young adults and adolescents, as well as for adults. But when they want to leave against medical advice (AMA), what is the solution? Residential programs are not psychiatric facilities where people are locked in when they are deemed harmful to themselves (suicidal) or others. That said, parents with minor children — and parents of young adult children — want to know that their child is safe. They don't want to hear that their child has run away. We talked to two large programs about the best ways to handle young people who want to leave.One, Rosecrance Health Network, treats adolescents ages 13 to 20 years old in its young persons' program, and takes the view that if young people want to leave, they should be allowed to. The other, Recovery Centers of America (RCA) based in King of Prussia, Pennsylvania, does not have an adolescent‐specific program but admits patients starting at age 18, and has a strategy of moves designed to encourage these patients to stay. Still, neither is locked.Evaluating motivation“In a residential program such as Rosecrance, the kids are asking to come,” said David Gomel, Ph.D., president of the Rockford, Illinois–based program. “There may be some parental coercion,” he said, so the first step is for the center to evaluate the teen's motivation. When the parents leave, it's the teen who is left in the program, which is unlocked from the inside. (“Like our homes, we lock it from the outside,” said Gomel.)If the patient is a young adult who wants to leave, Rosecrance looks for a “more appropriate place,” said Gomel. “We're not going to take someone who says, ‘I don't want to be here’ and make them stay, because that doesn't work,” he said. “We talk with the families to find something else.”Talking a walk, sometimes with a dogBut that doesn't mean patients are allowed to walk out the door unescorted. “My greatest fear of a young person trying to run away is for their own safety,” said Gomel. “By the time we've accepted them, we've ruled out the propensity of harm towards others or violence, but we're worried about these kids leaving and potentially hurting themselves,” he said.It's virtually impossible for a young person to leave without being noticed, said Gomel. “We have an adult counselor with our kids 24/7,” he said. And there is a protocol that a counselor would walk with the young person who goes out the door. “We are nestled in about 70 acres of woods and cornfields,” he said. “Kids are typically upset, angry, and in and of itself it's therapeutic to let them take a walk,” he said. But the counselor would be there verbally de‐escalating the situation, he said. “Sometimes, exercise alone will help,” he said.Gomel recollected the time when a counselor came to him describing a young patient who was agitated and “hell‐bent on not being here.” Gomel went to the patient with the program's therapy dog. “I said, ‘Let's take the dog for a walk.’” He laughed, adding that he “did very little; the dog and the walk did it all.” The young patient returned and recovered.‘All hands on deck’ to block AMA dischargeDeni Carise, Ph.D., chief scientific officer for RCA, doesn't have a specific adolescent program but does treat patients 18 years old and up. Like Rosecrance, treatment is not in a locked unit, but for the safety of the patient, RCA does make sure someone “has to go through a lot if they want to leave, especially if they want to leave on the spur of the moment.”When a patient wants to leave RCA, “it's all hands on deck to block this AMA,” said Carise. “The therapist, psychiatrist, nursing staff all reach out. We call their family and say leaving is a bad idea.” But she notes that “we can't force them to stay.”The first few days are the most critical for young people, said Carise. “We tell the parents there's a good chance your kid is going to call you tomorrow or the next day and say ‘I hate this place, I want to go home,’” she said. “We pre‐empt this by preparing the family for it.” And RCA has a blackout period in which the patients can't use the phone for the first five days of treatment.The therapeutic power of choiceThere is a therapeutic value to being in an unlocked facility. “These kids have to make decisions about their drug use, their peer relations,” said Gomel. Most are only at the Rosecrance residential program for a month. They have to go back to school and make decisions (Rosecrance has tutors so that they don't fall behind on their schoolwork when in treatment).Giving someone the power to know that it's up to them to stay — it's their decision — can actually make them less likely to want to leave, said Gomel. When a young person is walking into the facility for the first time, and says, “I'm not coming in,” Gomel will then tell the individual that the doors aren't locked, and ask him or her to go in on their own, and then to see that the doors aren't locked. “When they go in, and turn around, and realize they are not locked in, it takes away part of the fear because they know it's a choice,” he said. “I tell them, ‘I promise you, this is your decision.’”Carise agrees that it's important for patients — who by definition are impulsive since they are both addicted and young — to have a cooling‐down period when they want to run away, which can be managed diplomatically (like Gomel's dog walk).For example, staff at RCA lets the patient know that before they leave, they need to get prescriptions signed by the doctor and that they need to get their belongings (cell phone, money, etc.) that have been locked up. “There's a whole psychology behind allowing them to make their own choice,” she said. “There are some patients for whom we say — OK, let's get you started to go — and then they back down a little bit. We say, it's time for lunch; just have lunch first while we do your paperwork.” And then they change their mind.But there are patients who don't want their phone or their money back, and don't even tell RCA they want to leave. They just plan to leave. “I take this seriously,” said Carise. “If we see them leaving, we'll go after them. We say, ‘We don't want you to leave in your pajamas; let's get your clothes.’ And most importantly, we say ‘We want to get you a ride.’”
The Brown University Child and Adolescent Behavior Letter – Wiley
Published: Jan 1, 2018
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