REHAB JOURNEY
The continuum: Protection - Exposition
The whole rehabilitation process is structured evolutionally on two dimensions, which go from an extreme of total protection, on the first stages of the program, to a last stage of maximal exposition (all this taking into account the program limitations due to being a residential centre located on a normal social surrounding).
As an example, the residents have compulsory therapeutical mentoring and they transfer their own financial management to the Technical Team at a first stage, until, finally, nearer to the time when they will be discharged, they will be mainly responsible for their money and for their own actions.
Nevertheless, there are no fixed timeframes with regards to time of discharge or to the objectives achieved (mainly because they are different for each patient) and everything lies again on the need to meet the needs of each individual.
REFERRAL MANAGEMENT WITHIN THE TREATMENT NETWORK
Our experience
One of the basic aspects which sets the outcome of the rehab process is the aspect regarding the design of Rehab Itineraries (journeys), which will lead to the referral program according to the evolution of a case.
After five years collaborating with other resources from our network, and basing ourselves on our experiences, we would like to reflect about the adequate running of the referrals management. We would therefore like to highlight the following:
- Each treatment resource has a specific assistance nature which necessarily includes a group of patients (population susceptible of benefiting from it) and which excludes the rest of the target population at a specific moment in time. Only the Centres of Integrated Assistance (CAID, in Madrid) deal with all cases of drug dependency without any exception (that will not be discussed in this document).
- In fact, in this document, we will refer to the transition resources (especially residential) or those resources that complement the treatment carried out as outpatient resources on the Reference Centres (i.e. Treatment support flats, Self-management flats, Therapeutic communities, or other centres and programs such as vocational guidance services or professional skills courses, among others).
- Thus, all referrals to a treatment or support centre (whatever level or nature it has) should be integrated within a General Program of treatment, which we call Rehab Itinerary. It must adequately meet the patient’s evolution process and his/her treatment needs.
- Moreover, the referral request has to meet some technical requirements and, at the same time, must believe that the type of centre referred to is the only appropriate one for the patient at that point of his life, which, by default, would exclude all the other resources available for the treatment of other stages of the rehab process.
We mention this as, based on our own experience, we have observed how simultaneous referrals for resources of different nature are made (i.e. at the same time as someone is referred to a Treatment Support flat, they also apply for a vacancy on a therapeutic community or a Self-management flat).
Sometimes, the need that we feel to assist someone reaches such levels (sometimes the professional’s healthy interest in a patient leads to being too involved in a case) that we try to give assistance to the user, at any cost, without taking into consideration the nature of the resource the patient is being referred to.
In most cases, this leads to NOT reaching the therapeutical objectives, and also causes iatrogenic effects which could seriously lead to a relapse on the patient, who normally voluntarily abandons the centre and is exposed to the experience of a therapeutical failure (and we don’t need to mention the fact that it wastes the time at the treatment resource).
Resources setup
Each resource not only does it became categorized in “types”, such as two of the ones we manage at the moment, which are called “Treatment Support Accommodation and Social rehabilitation for people with dual diagnosis” but also has specific objectives and is addressed to a specific phase on the rehab process. This means that normally we have to describe a Candidate’s Profile in order to access a resource.
About the User Profile
However, it is rarely the occasion when a profile can be sufficiently defined in order to benefit the target population that can take advantage of the resource, specially if we take into account the diversity which exists among people with Dual Diagnosis, so this forces us to make the profiles broader, though, nevertheless, the profiles still have to comply with the following requirements:
- The profile of the user’s needs, and the technical potential of the resource to meet those needs must fit. In other words, the feasibility of the user’s therapeutical process, who must complete a new stage in a transition resource.
- The candidate’s adherence to the centre’s regulatory framework (in the case of the residential resources integrated on a normal social surrounding, this Team believes it is essential that the user is capable of and willing to comply with some minimal elements which will make an adequate cohabitation possible, not only inside the flat, but also with its surroundings).
- The upkeeping of the accommodation shared with other users, which must be kept in good working order, and that will be supervised by the management team of each of the centres (sometimes there are users who, with or without personality disorders, put the centre at risk, or commit a physical or psychological offence against the group they live with, or tell the neighbours about the nature of the activity carried out in the centre, etc).
Maximums and minimums:The technical setting of the centre
We have previously mentioned that there is a user profile for each resource, which by default implies that there are candidates who, at a point in time, are not ready to access a specific resource, as well as there are other users who have a higher capability to the one they could obtain if they completed the treatment process of the resource.
This is more easily observed if we look at the management of our residential resources: we have encountered many times candidates who are not ready to access our resource, either because they were not psychopathologically stabilised, or because they were using drugs; or simply because their pathology recommended that they were referred to other specialized resources.
In some occasions (noted, rarely) we have assessed candidates who already had achieved the main capabilities that they could acquire at our accommodation: they showed a high degree of independence and interpersonal competence, and they were even leading an independent life.
The problem is that it is difficult to explain specifically what the minimums and maximums thresholds are in order to be accepted into one of our flats. We normally have to explain, on the returned application form, the reasons why a candidate was rejected (either because it didn’t meet the minimum requirements or because it exceeded the maximums).
The resource as a treatment device
Continuing with the specific example of the residential centre, we have observed that, in numerous occasions, the patient is referred there simply because there are no other alternatives of accommodation. In those cases, and frequently we have detected that circumstance when interviewing the candidate, we have rejected the application if one of the following is not met: consolidated abstinence, problem awareness and desire to change, or adherence to the treatment, among others.
This has sometimes led to intense disagreements with the professionals who referred the case to us, as, probably due to the fact that they do not know the programs developed in our centre, they do not understand how we can reject an application when someone needs accommodation.
We never contest the need for accommodation. However, Social Services has other alternatives for people who only need accommodation (that is, patients who are not prepared, at the moment of their referral, to comply with or benefit from our treatment).
Sometimes, the referral is not motivated by a need of accommodation, but for a need of immediate restraint. Even then, the candidate has to comply with the acceptance profile, or the strategy risks being unfruitful.
Our thoughts about this are the following: it would be unthinkable that someone who needs a gardening course in order to opt for a job vacancy is referred by a vocational guidance professional to a Professional Skills College without taking into account the courses they teach there (IT or Nursing, for instance). It would even be more unthinkable to refer him to school, where he has already been, to meet his needs (he would exceed the maximum requirements) or to enrol him at university (he does not meet the minimum requirements).
This example, though obvious, is a frequent case in our everyday running: the need for accommodation or restraint, is, in too many occasions, the main motivations (if not the only ones) when applying for a vacancy at our residential centre.
In the previous example, no one would doubt in accusing the Vocational Guidance Technician of incompetence, as his/her determination to offer skills to his client would misguide and impair his training progress.
But we do not doubt the professional capabilities of our network colleagues, quite the opposite; we understand that they are trying to meet the assistance needs of all their patients, especially the more complicated ones. And it might be exactly there that lies part of the problem: the development of assistance careers (as so is the writer’s) might lead to the risk of over-implication on a case. In other occasions, the scarcity or lack of resources forces professionals to refer the patient to the resource that fits in more with what the patient needs, or sometimes, due to the lack of possibilities, to refer patients wherever.
Good examples of this are our residential centres for people with Dual Diagnosis. Frequently, when facing a refused application (which is always explained in writing) we are accused of not treating a patient who has Dual Diagnosis, when we are in fact a centre specific for that pathology. And that is rightly so, but that does not mean that we have the capability to take in charge the treatment of any patient with Dual Diagnosis (we wish we could!). We insist that we have a resource which has a specific set up, and that, although it is highly flexible, it has its limitations.
Consequences to an inadequate referral
Two possible outcomes might take place:
a) The candidate manages to be admitted to our centre
This happens frequently when the patient has undergone a task of awareness with regards to the benefits that our centre might represent for him, and he manages to answer the assessment interview questions as if he has been prepared for them.
In this case, the professional is more motivated than his patient in his rehabilitation and this bears some consequences on the short and mid term. According to our experience:
- The patient abandons voluntarily the centre because he is not willing to bear the cost of his part of the compromise: He doesn’t wish to have therapeutical mentoring, he does not accept that his money is managed for him, he will try to avoid carrying out his responsibilities, etc.
A voluntary discharge will, in general, take place and the patient will be the one to request it. How long it will take him will depend on the benefits he is getting from the centre at any one point in time, as well as on the intensity of the therapeutical pressure.
- During his stay, he will not commit to the therapeutical activities and he will make some little efforts in order to have a higher degree of freedom or spaces for his own enjoyment.
As there will be no real therapeutic engagement, the user will conceal the relevant information, which, at the same time, will seriously compromise the capability of progressing.
- The probability of causing conflicts will increase in the flat, and so will the difficulty of them being solved by the professionals. This, in turn, will noticeably undermine the cohabitation environment.
- Moreover, there will be a higher probability that the resident uses drugs in spite of the rules and that would deteriorate the minimal progress that might have been achieved. In those cases, the repetition of the use of drugs is practically assured (as there isn’t a clear wish to stop taking them) and the end of their stay in the flat will end dramatically with exclusion.
- In general, once he has been excluded from the flat, the user will develop a serious process of relapse.
b) The candidate is rejected before (in the pre-report stage) or after the assessment interview
- In this case, the professionals who referred the patient will receive a written report explaining the reasons for the refusal, though normally they do not give those arguments any weight and insist on the immediate need of the patient which leads to technical discussions, at the best of times, or it creates suspicions among professionals.
- The latter aspect worries us because: both the language used and the content of the discussions amongst professionals linked to the network should remain technical. We should never play the game of personal accusations (especially when the professionals don’t know each other personally), and we should, even less, deteriorate or delete altogether a referral process which could help many other patients (in this sense, and as a sad anecdote, we should highlight that those centres which receive more than one refusal – because of candidates’ profile inadequacy- normally tend to reduce or stop altogether the referral of patients).
Information transfer:a facilitation proposal
To mend and resolve the previous situation, we think it is essential that the professionals of the network have a deep understanding of the existing resources (even by visiting them).
In fact, whenever there has been previous coordination between the receiving and the referring centre, there is a higher probability that a referral fits the profile. That is, those who better know the resource, what it consists of, which population it attends and what type of treatment it offers carry out better referrals.
Previous professional cooperation between the Centre that makes the referral and the centre referred to, diminishes the distrust when a refusal takes place. In fact, it is normally the Centre itself that, during their internal meetings, decides which candidates are inadequate and don’t refer them.
This is of enormous importance: the higher the amount of inadequate referrals, the more problems we will have with our waiting list, which is organized by date of referral. That means that, in order to satisfy the assistance needs of a case (even if it doesn’t fit the profile), we are increasing the waiting time to access our resource by other patients who do fit the profile.
And in this sense, the person that suffers most is the patient who is in the waiting list and sometimes has returned to the family home after being on a previous centre (a patient that obviously needs to continue the treatment at our accommodation) and that, due to the delay on managing his application, finds himself in a high risk situation.
To conclude, we highlight two parameters as good predictors of a referral’s success:
- information regarding our resource, and
- previous communication between the professionals.
