Relapsing in Rehab—the problem of free-riders.

Recently, one of the houses discharged several clients for drug use. I was sad to hear the news. I liked some of the people that were discharged.

In a documentary I watched several years ago—I am paraphrasing here, but—I heard something like this,

“discharging an addict for relapsing is like discharging a heart patient for having a heart attack.”

When I first heard the statement, I thought, “Fair enough.” Discharging for relapsing is equal to denying services to someone when they need them the most.

But the more I’ve worked in and around rehabs, the less I agree with the statement.

I spoke with a staff member from the house that discharged several clients. The conversation solidified some ideas that have been swirling around in my head for a while.

I shared with the staff member something that was told to me by a former client from another house. I was still trying to understand the significance of what the client said, which is why I brought it up. Maybe the staff member could help me make sense of it.

The former client said that a fellow resident left rehab on a half-day pass—and when he came back, he was obviously high. The staff were debating what to do about it when my client spoke up. He said, “if you let this guy back in, I will relapse.” As my client told it, the threat of discharge was one of the factors keeping him sober.

I’ve thought about his statement for a while. I remember being impressed with his resolve, but, somewhat at a loss to explain why he was right.

Are replases contagious? Do those who relapse ooze little addiction germs into the air and sicken others?

Probably not.

But what is going on? Why is it so important to discipline relapsers?

Perhaps “group resolve” is the reason it is so important to discharge those who relapse. Maybe clients in rehab are taking a risk. Each client is a soldier in battle. Each person’s resolve strengthens the others. The battle is significant, in part, because everyone is fighting together. The cause is worthy because each is depending on the other for strength and courage. Defectors bring down morale. A client can start to question whether staying in the battle is worthwhile. If my brother-in-arms lays abandons his post and deserts, why should I keep fighting?

Harsh discipline may be required, even desired, by the soldiers. Without it, lives can be lost. Sobriety becomes a casualty.

I am not sure if my battle analogy holds up. But, the staff member told me some of her own reasons why discharging the relapsers was necessary.

Some residents had begun to think the staff and owners were, “just in it for the money.” This is a particularly difficult dynamic. Many of the owners and staff are African immigrants. Ethnic and cultural differences can strengthen an “us against them” form of tribalism. If clients believe that staff are “just in it for the money” the sense of legitimacy clients feel toward the program declines. Clients often refer to this legitimacy as “seriousness” as in, “this place doesn’t take my sobriety seriously.” In that climate, discharging clients—and taking the financial hit for it—can change perceptions. “Maybe these guys really do want to help?”

The staff member also said that allowing clients to stay after a relapse made her job pointless. She dreaded coming to work. It was as if she were building furniture all day only to have her furniture disassembled each night. What was the point of all the work when it was just being undone? The way she described it, I had images of the Twilight Zone, Kafka, and Bergman films. . .Existential despair. Nothingness. Death playing chess with an old professor. . .

I’ve recently learned a concept from economics that seems to offer an explanation, too. It is called the “free-rider” problem. From an economic perspective, the sober people in rehab are paying their club dues, by which I mean they are working hard to avoid using substances. The “working hard” is a form of dues or taxes.

People who relapse while in treatment are “free-riders”. Imagine the feeling at a graduation day when one person stayed sober for 3 months, and another person kept sneaking drinks and drugs the whole time. Does it seem fair they both get the same certificate, applause, and hugs? No. The free-rider is getting all the benefits of being in rehab, but they aren’t paying their dues. When rehabs don’t punish relapsers they are allowing “free-riders” at the expense of those who are working to stay sober. Those who stay sober may begin to think, "why am I doing all the hard work of staying sober when nothing happens to [the relapser]?"

When rehabs allow “free-riders,” clients also lose respect for the rehab. And respect for the legitimacy of the rehab is important. Without that sense of legitimacy, clients begin to wonder if it is worth continuing to work the program. They may say to themselves, “I am not going to work this program. Even the leaders don’t take it seriously. So why should I invest my time and energy into working this program?”

So, clients are hurt twice when free-riding is allowed. First, clients feel cheated because they are paying their dues when others are getting a free ride. That is a problem of fairness. Second, clients start to doubt the legitimacy of the rehab because the rehab doesn’t seem to really respect itself.

Here is a song about doing the right thing by the great Jim and Jesse.