Rules of Rehab: Arbitrary or for Good Reason?
I was introduced to the “rules of rehab” by a client at a high-end, non 12-step addiction treatment program, one that encourages client autonomy and doesn’t have a lot of rules. (It was one of the first treatment programs I visited while researching Inside Rehab.) In the past, he’d attended very different facilities, including one he described as a “lock-down” rehab.
As he described it, “You couldn’t leave the premises without an escort, and you had to sign in and out for meals. I thought the next thing they would do is shave my head and de-louse me! It was an awful feeling of confinement and debasement.” He also was denied access to his cell phone as well as reading materials that were not 12-step oriented.
Since these and other rules that are unheard of when treating other conditions or diseases seem to be fairly common at addiction rehabs, I decided to run some that I came across by experts in the field. Overall, Mark Willenbring, M.D., founder of St. Paul, Minnesota’s Alltyr addiction treatment clinic and former director of the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism, said, “The rules are a throwback for the most part, and are a mix of pragmatic needs and guidelines for a spiritual retreat. Most 12-step rehabs are authoritarian and intrusive.”
Following are some specific rules of rehab that I encountered, along with commentary by experts in the industry:
- No cell phones or computers allowed (or access greatly limited, perhaps to one supervised hour per week) on the grounds that clients might contact drug dealers or violate other clients’ privacy – for instance, by taking photos. Another reason for the rule is to limit outside distractions in order to help clients focus on treatment. In Dr. Willenbring’s opinion, it makes sense not to allow people to use their phones during groups, “but when it comes to the ‘spiritual retreat thing,’ it doesn’t make much sense for people getting exactly the same treatment for the fifth or fortieth time.” (In other words, people who have a recurrence of their substance use disorder and go back to the same type of rehab already know the drill.)
At Practical Recovery’s non 12-step rehab facilities in San Diego, in some cases, restrictions may be needed to lower the chance that communicating through them will result in drugs being delivered to the rehab. However, their philosophy is to start from a position of client trust and to not use one-size-fits-all rules. Founder and director Tom Horvath, Ph.D. said that cell phones and laptops are allowed unless there’s a problem. Dr. Horvath added that for only a small number of people, “A complete transition into a new world is needed, to include no TV, computers, or cell phones.”
- No reading materials that aren’t recovery-related or “spiritual.” Dr. Willenbring’s reaction was, “Limiting reading materials is obviously based on the spiritual, contemplative retreat idea. Nothing wrong with a spiritual retreat, but this is not ‘treatment.’ All of this reminds me of the absurd advice often given to patients not to work [professionally] so they can ‘work on their recovery.’ I’ve never quite figured out what ‘working on your recovery’ consists of.” While working on recovery-related assignments – such as a relapse prevention plan – may make sense, might it not be helpful to learn how to relax and enjoy yourself by reading a good novel (non recovery-related) as an alternative to using chemicals for pleasure?
- If allowed at all, movies, TV, and/or music cannot have triggers for “use.” As I said in my book, “This is something that I thought rehab is supposed to help you learn how to negotiate.” Dr. Willenbring was a bit more strident with, “Avoiding triggers while in a rehab facility is one of the stupidest ideas of all. If you can’t practice while inside the ‘program,’ then you’ll be flooded with triggers after discharge but will have had no practice to develop skills. Rules like this are counterproductive because you cannot develop a skill until you practice it. In fact, you’d want to induce craving and desire with cue exposure while in rehab in order to develop skills to manage them. It would be like being taught how to play basketball in the classroom, with no gym practice, and then expecting to be an effective ball player after school is over.” Dr. Horvath added that some clients need help with “developing a higher level of self-regulation, which allows for the pursuit of goals, which in turn protects against relapse.” He explained, “Often, clients don’t have regular schedules for sleeping, waking in the morning, eating regular meals, getting exercise, and participating in activities. A degree of external discipline can be helpful, particularly in a younger person. So TV may need to be limited as part of that.”
- “To protect the integrity of the program, it is necessary to have a staff person observe you produce a urine sample.” Thus read a sign on the wall of a famous rehab, reflecting a practice that I personally found demeaning. Such practices are “the industry standard” according to Dr. Willenbring. Yet in his clinical view, they’re almost never necessary because test kits are available that test for dilution and adulterants and that also check for temperature immediately after collection. (It’s very hard to artificially get urine into the 90- to 100-degree body temperature range artificially.) It helps to have a bathroom with no sink and a toilet with blue water so it’s obvious if someone tries to dilute urine with it.
At Minnesota Alternatives, an outpatient facility specializing in treating people with substance use and mental health disorders, founder and director Paula DeSanto, MS, MSW said they don’t do a lot of urine testing because that’s not part of their “welcoming and accepting” philosophy. If clients feel safe to share about their substance use, there is less need for UA’s. “We don’t need to ‘catch them’ because they are honestly reporting. We generally test if a client wants one done to increase his or her own accountability – for instance, if a tough weekend is anticipated.”
- “No fraternizing” (no male/female relationships while in rehab) and no acceptance of couples who want to attend rehab together. At one facility with separate tracks for young men and women, they weren’t even supposed to look at each other. At another, clients were warned not to approach any non-staff male while in treatment, including when they were taken to the YMCA, grocery store, and AA meetings. The saddest case was that of a young man who’d attended many rehabs and finally had several months of doing well at one that made him leave because of what was deemed an “inappropriate relationship” with a female. (According to his father, they were just friends and not romantically involved.) A while back in an article in Counselor magazine William White, M.A. and colleagues, aptly made the point, “One is hard-pressed to find other arenas of health care in which sexual prohibitions are a condition of continued service access.” It makes sense for there to be rules against having sexual relationships going on in a residential program – or at least to minimize them – as Dr. Willenbring says, “because there’s too much potential for conflict and for women in particular to be victims.” And it’s not wise for intimate partners to be in the same treatment groups, unless it’s group couples therapy.
Creating such artificial boundaries reflects rehabs’ belief that sex and relationships are somehow inherently unhealthy and dangerous.-Dr. David LeyPsychologist David Ley, Ph.D., Executive Director of New Mexico Solutions and author of The Myth of Sex Addiction stressed, “Blanket guidelines about male/female relationships are too one-size-fits-all.” His advice for rehabs? “Services should better prepare patients for being on their own by mimicking the real world, which obviously doesn’t separate by gender or prohibit relationships. Creating such artificial boundaries reflects rehabs’ belief that sex and relationships are somehow inherently unhealthy and dangerous. In individualized, affirmative, and recovery-oriented treatment that uses a more case-by-case approach, blanket prohibitions are outdated, foolish, and likely to impede long-term recovery.”
What about couples who want to attend rehab together, as did one couple I interviewed? One of them shared, “There were so many times we wanted to go places to get clean, but time would go by and the moments would pass because they [rehabs] wouldn’t take us as a couple. And we were willing to pay whatever it cost.” After they finally found a place willing to work with both of them, the woman in the couple told me, “Getting sober together was what worked.” Barbara McCrady, Ph.D., who studies the role of couples therapy in addiction treatment and also directs the Center on Alcoholism, Substance Abuse, and Addictions at the University of New Mexico said, “There are not scientific data backing the notion that couples should be separated in treatment, so flexible decision-making rather than a blanket rule makes the most sense.”
Avoiding triggers while in a rehab facility is one of the stupidest ideas of all. If you can’t practice while inside the ‘program,’ then you’ll be flooded with triggers after discharge but will have had no practice to develop skills.-Dr. Mark Willenbring
In the end, “Rules are conflict generating – they give providers all kinds of reasons to be critical, and provide convenient reasons to kick people out of treatment,” maintains Paula DeSanto. She added, “Rules disempower clients, tying into the idea of powerlessness – not only are you powerless over your substance use disorder, you’re powerless in our treatment setting. Finally, rules send the message to clients that they don’t need to think. How do rigid settings prepare and teach people to learn to manage their lives?”
Disclosure: Anne Fletcher works part time as Recovery Coaching and Family Services Specialist at Minnesota Alternatives
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