Determinant of Optimal Length of Stay
by John Derry, B.Sc.Phm., M.A.
Length of stay in primary residential treatment for chemical dependency has been the subject of much study and debate. Historically, one-month programs became 28 days and, with the advent of healthcare management and the pressures of cost containment, some programs became 21 days. Thirdparty providers became the decision makers. While it is intuitively obvious that the longer the immersion in primary treatment, the better the outcome, it remains unclear as to what is the optimal "standard" primary treatment duration. Is 28 days sufficient to effect meaningful and life altering changes adequate to sustain recovery?
In 2004, a small and unique recovery facility located in British Columbia, Canada began as a 28-day program. The program incorporates the Minnesota model of recovery with intensive cognitive-behavioral counseling, holistic therapies, and a twelve-step philosophy. Clients are treated with dignity and respect as guests in a beautiful home with private bedrooms and chef-prepared meals. Accepting no more than eight guests at a time, each guest receives individual attention. The small setting and family-like dynamic fosters intimacy and a sense of safety and trust.
At this recovery facility, the clinical staff began questioning the length of their program as they noticed an increasingly prevalent therapeutic recommendation for extended treatment in their clients undergoing the standard 28-day program. Strategic decisions, such as this one, demand a methodically rigorous approach, including a review of the available literature and benchmarking against other leading institutions.
In the midst of this contemplative state, an answer came to them loud and clear from one of their clients. Patrick L. was a robust and handsome man of 51 years of age. Highly successful in his business, and wealthy in the material realm, he came from a large, affluent family. Patrick built and directed what had grown to be a very large, highly profitable corporation. He had it "all," yet he could not stay sober.
Patrick made his first contact with the treatment program with a firm conviction that he needed help. Patrick had continually relapsed after three prior treatments at traditional institutional drug rehab facilities.
Arrangements were made and he was welcomed to the recovery facility within the week. Patrick committed to the core 28-day program, yet, given his history of relapse, he recognized and discussed the possibility of staying longer. Guests had an option to stay up to three months based on need and clinical judgment. At the time of Patrick's committing to the program, he stated that he would stay as long as he was directed because he "knew this was his last chance."
During his first two and a half weeks of treatment, Patrick made tremendous strides in his recovery. He worked hard through many difficult issues and made several dramatic leaps forward. Longstanding resentments were successfully treated with forgiveness; he connected with his own understanding of a Higher Power, and seemed to have made peace with his God, himself, and his fellow human beings. With the support of the group and individual counseling, he accepted the recommendation not to return immediately to his home city. He planned to stay for three months with his recovery program sponsor in another city.
At this stage of his recovery, Patrick also began to explore options to re-direct his career and return to study. Patrick came to recognize a new passionate calling, to help others with their addictions. It was clear he was starting to love himself and others again.
On one recreation day, he went to the mountains with others from the program and delighted in being back on skis, an old passion he had long ago given up. He laughed and shared stories with others on the chair lift. He said he could not remember ever having so much fun.
During Patrick's following week-and-a-half of treatment, as he approached 28 days, his attitude was noted to have shifted to deciding he knew what was best for himself. Despite feedback to the contrary, he began to correspond and attempt reconciliation with a prior toxic and unhealthy relationship. He secretly changed his plans to return to his home city and that relationship. A counselor at the recovery facility challenged Patrick on the change in his behavior and his unhealthy thinking. Patrick was told that his disease had taken back over and was convincing him he knew best. In language common to twelve-step fellowships, he had "taken back his will." It was strongly recommended that Patrick stay a minimum of two additional weeks, and to be open to staying as long as the optimal time of three months. No amount of counsel or suggestion could sway Patrick. He remained in a euphoric mood until he left. He told his focal counselor that he would at least heed the recommendation that he not return initially to his hometown and his girlfriend; instead, he would stay with his sponsor.
During his goodbye medallion ceremony, Patrick broke down in tears of gratitude. He thanked the staff and stated that he was "the happiest he had ever been" while at the treatment center. The clinical staff knew he wasn't ready. He was told this yet again, with conviction and compassion during the ceremony, which ended in tears and hugs.
Patrick left the treatment program and, against all recommendations, flew directly to be with his old girlfriend in his home city.
Less than two weeks later, the recovery facility was informed by Patrick's business partner that Patrick had taken his own life. He had relapsed two days after returning home. The shame of drinking again was too much for him to bear.
This tragic event became a turning point for the facility leadership. They felt that, in good conscience, they could not continue to offer a 28-day program. It became increasingly clear that 28 days is barely enough time for most people to begin their healing process, much less cement new habits and ways of thinking. And, in those that agree up front that an extended stay would be optimal, leaving the decision to stay until part way through primary treatment usually resulted in the choice to not stay beyond the core program length.
The leadership team had been seriously thinking about increasing the program to six weeks, or 42 days, but had wondered if it would deter some folks from committing. Would this have a negative impact on call volume and rate of intakes? After the devastating news of Patrick's death, it immediately became clear that, regardless of business considerations, it was no longer ethical to offer the 28-day program. One such death was one too many. Without further study or deliberation, the treatment facility stopped offering 28-day stays and increased the core program to 42 days.
Patrick had the opportunity to love himself and discovered what he thought to be his calling in life: to help others who suffered from the disease of addiction. In the end, he made the ultimate sacrifice to do just that. Through his death, others could be reminded of the powerfully fatal nature of this disease and the need for appropriate care. Patrick's life and death motivated the change to the new 42-day program as the minimum, so that others might have a greater chance at a life of recovery. The very harsh reality of his addiction is that Patrick paid the price so that others could be helped. Patrick's experience was an "N of 1 study"*: he was investigator, subject, outcome, and conclusion.
The dramatic differences guests now experience during the last two weeks of their program illustrate and honor Patrick's last wishes. He was, is, and will remain a very special person in the life of this unique recovery facility. Patrick's memory will forever be held with great respect and gratitude.
When faced with such strategic decisions, when considering all possible inputs, let us remember that what really counts is what is in the best interest of our clients. They trust us with their lives, and don't know what they need. They count on us to make the "tough calls." Our clients, not the finance or intake departments, provide endpoints that should guide our decisions.
Death is an endpoint that is unmistakable. Patrick gave his life as a gift so that others could have theirs. We owe it to him, and all who follow, to pay attention.
John Derry is a licensed pharmacist and holds a Master of Arts degree in Addiction Counseling from the Hazelden Graduate School of Addiction Studies. After 20 successful years as a pharmacist and manager in hospital and corporate settings, he shifted his career focus to alleviating suffering from the disease of addiction. John founded A Home Away, located in British Columbia, Canada, as an innovative model of addiction treatment, offering compassionate, professional care in a home setting. He has an impressive track record of success and is known for his outstanding interpersonal, communication, and leadership skills. He offers a unique depth of expertise based upon his complementary proficiency in both pharmacy and addiction. His credentials and professional experience distinguish him as an expert in his field. For additional information visit www.ahomeaway.org.
* scientific research involving one individual subject
Ref.: John E. Derry, Paradigm magazine, 2009; Vol.14 (Issue 2): p 4-5.
