Wednesday, July 18, 2012

The Sweet Spot

When it comes to how long clients stay in treatment, there seems to be a "sweet spot." When clients discharge prematurely, they are at greater risk for relapse, either because there are more residual/unresolved/partially-resolved symptoms, or because progress/changes made in treatment are still new and therefore harder to sustain (or both reasons). These risks seem relatively obvious - widely accepted among practitioners, and cited in textbook discussions on termination.

Less widely known/discussed are the risks of clients staying too long in treatment. There seems to be a window during which clients are ready for discharge, and able to sustain progress without treatment at the current level of care. Symptoms have resolved sufficiently, and their developmental momentum is in the direction of health and recovery (helping them continue forward movement after treatment ends). However, if they linger too long in treatment, the momentum shifts - the treatment may stagnate, or even regress. Symptoms may reemerge and motivation may flag. Discharging a client with this kind of momentum - away from, rather than toward, health and recovery - also poses a greater risk of relapse...perhaps even more so than clients who discharge too early.

While it is easy to describe this "sweet spot," in practice, it can be deceptively hard to hit. There are several factors that make it challenging to gauge a client's readiness for discharge:

  1. Uncertainty about whether symptoms are resolved "enough" (given that there is probably no person on earth who is truly free from all mental health symptoms!) - clinicians may find themselves second-guessing whether the client is actually free of "clinically significant distress," or whether residual symptoms are harbingers of a coming relapse.
  2. The client's own anxiety about discharge - often, clients doubt their own ability to maintain changes without the support of treatment, and the idea of discharge may send them into a tailspin. Clinicians may be reluctant to discharge a client if s/he is uncertain about wanting discharge, and/or the client's anxiety may be contagious and make the clinician also doubt his/her readiness.
  3. Attachment - the client's attachment to us, and our attachment to them, may make both parties reluctant to discharge due to anticipated grief.
  4. Agency culture - Some clinics operate on the principle that clients should receive as much treatment as insurance companies will authorize. And while insurance companies do their best not to authorize more treatment than the client genuinely needs, it's not a perfect system (after all, all they have to go on is what clinicians tell them!). Accrediting bodies (which are different than payors!) require that clinical decisions be made based on clinical presentation and not on insurance. While it may keep clients in treatment as long as possible, it's not good for clients, and it's not ethical practice. We all need to be in the habit of using our clinical judgment rather than being guided by insurance.
How do you think about readiness for discharge? How do you find the "sweet spot," and what makes it difficult?

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