Against Medical Advice (AMA)

Leaving Addiction Treatment AMA

“I’m not as bad as these other people.”

“I’ve got responsibilities to take care of at home.”

“I know what I need to do.”

“I only need detox.”

These are some of the most common reasons we hear from clients who want to leave treatment early. In medical parlance, we call this leaving Against Medical Advice or leaving AMA. It’s a heart-breaking outcome because we know that the best predictor of treatment success is length of time in treatment; the longer you stay, the better your chances of staying sober [5].  One of the hardest reasons for leaving to hear is also one of the most honest: “I’m just not ready to get sober.”

All of the reasons listed above relate to motivation. It’s a common theme in addiction. Slogans about hitting “rock bottom” suggest that there is a breaking point that needs to be reached to be ready to give up our alcohol or drugs, but that rock bottom usually comes long after we’ve destroyed our relationships, careers, health. Sometimes, it never comes.

The truth is that wanting to leave treatment doesn’t necessarily mean that we lack motivation. There are two type of motivation in recovery: motivation for change and motivation for treatment [1].  A person may have serious motivation to stop using or drinking, but that doesn’t necessarily mean they are motivated to do the challenging, frightening, difficult work that treatment necessitates. Facing our past, facing our sadness, facing our fears; none of those things are easy, and doing it without the comfort of a drug or drink? That can be terrifying.

Even more challenging is the fact that our brains are working against us.  Drug and alcohol use has been related to deficits in the ways our brains process information and emotions.  We react to negative events and emotions more than we react to positive ones; the good things just don’t hold as much weight as the bad [2, 3]. We’re impulsive and have a hard time planning things.  Immediate rewards seem much more important than rewards that could be greater but are farther away [4]. Logically, we know that the benefits of getting sober will be bigger than the brief pleasure or comfort of a drink or a drug, but it’s hard to remember that when we are uncomfortable or upset.

When we take all of this into account, it makes perfect sense to want to leave. We know that the moment may come where a client says, “I can’t do this.” It’s the reason that BHOPB looks at each and every client that chooses to leave treatment early; is there anything we could do differently? Is there any way to make the process more comfortable?

We know that getting sober and entering treatment is often the bravest and hardest thing that our clients have ever done. We know it isn’t easy. But we also know that with support, with time, with encouragement, we can get through those dark, hopeless, panicked moments. They will pass. It is hard, but it will get easier.

  1. de Weert-van Oene, Gerdien H, Gongora, V., von Sternberg, K., & de Jong, Cor A. J. (2015). Motivation for treatment and motivation for change in substance-dependent patients with co-occurring psychiatric disorders. Journal of Psychoactive Drugs, 47(5), 393-400.
  2. Fernández-Serrano, M. J., Pérez-García, M., Perales, J.C., & Verdejo-García, A. (2010). Prevalence of executive dysfunction in cocaine, heroin, and alcohol users enrolled in therapeutic communities. European Journal of Pharmacology, 626(2010), 104-112.
  3. Fernández-Serrano, M. J., Pérez-García, M., & Verdejo-García, A. (2011). What are the specific vs. generalized effects of drugs of abuse on neuropsychological performance? Neuroscience and Biobehavioral Reviews, 35(3), 377-406.
  4. Stevens, L., Verdejo-Garcia, A., Roeyers, H., Goudriaan, A., & Vanderplasschen, W. (2015;2014;). Delay discounting, treatment motivation and treatment retention among substance-dependent individuals attending an in inpatient detoxification program. Journal of Substance Abuse Treatment, 49, 58-64.
  5. Turner, B., & Deane, F. P. (2016),” Length of stay as a predictor of reliable change in psychological recovery and well being following residential substance abuse treatment “, Therapeutic Communities: The International Journal of Therapeutic Communities, Vol. 37 Iss 3 pp. 112 – 120

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