Outpatient Addiction Treatment

Outpatient addiction treatment is specialist therapy for addiction delivered while a person continues to live at home and go to work, rather than as a residential stay. Sessions may be weekly, twice weekly, or arranged as an intensive block of consecutive days.

The question behind the question

Most people who look for outpatient addiction treatment are really asking something else: do I have to go to rehab? Underneath that sits a fear of disappearing from your own life for a month, and of what it would say about you if you did.

It is a fair question, and it deserves a better answer than a brochure.

Dr Jacquet’s Model of Growth

Residential treatment works, while you are in it, and it is worth being precise about why. It is not the country house and it is not any single therapy. It is that a clinic constructs four conditions around a person, and those four conditions together produce something that can be called a safe place.

Rules. No drugs. No alcohol. Often no sugar. Attendance at group is not optional. Lights out at a set time. The rules are explicit, and crucially they are held by somebody other than you, so that keeping them is not a decision you have to make forty times a day.

Structure. Broadly, eight hours of sleep, eight hours of work on yourself, and eight hours of everything else: yoga, relaxation, reading, television, company. The day has a shape that you did not have to invent when you woke up.

Routine. A schedule that tells you what happens at each hour. This is the wall people underestimate, because its real function is not organisation. It is that knowing what comes next removes anxiety. Nothing has to be anticipated, decided or defended.

Support. A therapist, a psychotherapist, a doctor, a nutritionist, a group, night staff. People who are reliably present and who already know what is going on, so that nothing has to be explained from the beginning.

Take away any one wall and the safe place stops existing. Which means safety is not a mood or a quantity of willpower. It is an output. Something produces it, or nothing does.

The model set out for clinicians, and what it implies for discharge planning: The Walls Belong to the Building.

Why the safe place is what stops the using

Here is the part that matters clinically, and it runs in a sequence.

The four walls produce the safe place. When a person feels safe, self-esteem rises, because they are managing, they are keeping the rules, and nothing is going wrong. And when self-esteem is up and anxiety is low, the wish to use simply is not there. Anyone who has worked in a clinic has heard the same sentence many times: since I have been here, I have not once thought about using.

That sentence is usually taken as evidence of progress. It is better understood as evidence of the walls.

Why the walls do not come home with you

In residential treatment, all four conditions are built out of the institution’s materials. Its rules. Its timetable. Its staff. Its building.

So a person leaves having accumulated something real, but not the thing they will need. They have weeks of not using inside an environment engineered so that using was not possible. They do not have one day of not using in their own life, with their own job, their own kitchen, their own Friday evening, their own reasons.

Then they close the door of the clinic behind them, and the sequence runs in reverse, quickly. The structure disappears, and the safe place goes with it. Self-esteem drops. Anxiety rises. And using is, among other things, an extremely effective way of not feeling anxiety.

That is what a relapse after discharge usually is. Not a collapse of motivation, not a failure of commitment. The supports of the safe place were withdrawn all at once by an arrangement that was always temporary, and the anxiety they had been holding came back with nowhere to go.

A few weeks clean, and not one wall of your own.

Recovery is building your own four walls

If the model is right, the work is unambiguous: recreate all four conditions inside the life you actually live, out of materials that belong to you. This is what a great deal of the work here consists of — deliberately building a safe place outside the four walls of a clinic, in real life, where it will have to hold.

That means answering four uncomfortable and entirely practical questions. What are your rules, as distinct from the clinic’s? What structure survives your job, your commute, your children, your travel? What routine holds when nobody is watching and nothing is being monitored? Who is your support at eleven o’clock on a Tuesday night, and do they actually know?

None of those can be answered in a place where none of them apply. They have to be built and tested where they will have to stand, which is precisely the environment residential treatment removes you from. That is not rehab-lite. It is the part residential treatment structurally cannot do.

When residential treatment is the right answer

Some people need the borrowed walls first, and saying otherwise would be dishonest and dangerous.

Withdrawal from alcohol or from benzodiazepines can be dangerous and occasionally fatal without medical supervision. If you are physically dependent, a medically managed detox comes first, and no amount of psychotherapy substitutes for it. The same is true where there is serious physical compromise, an acute psychiatric presentation, or a living situation in which the using is genuinely inescapable.

Where that is the case, you will be told plainly at assessment, and helped to prepare for it. Being told honestly that you do need a clinic is worth as much as being told that you do not.

An honest answer, from someone who does not sell beds

A residential clinic cannot give you a disinterested answer about whether you need residential care. This is not a criticism of clinics; it is simply what happens when the assessment and the bed belong to the same organisation.

Dr Philippe Jacquet spent nine years working inside residential treatment, trained at Hazelden, and today supervises the clinical teams of a private residential clinic and a private psychiatric hospital. He is, in the most literal sense, one of the people who supervises the clinicians who would be treating you. He has no beds to fill.

As much or as little as you need

The work is arranged around what the situation actually requires rather than around a fixed programme.

• Weekly sessions, the ordinary shape of sustained individual work.
• Twice weekly, where things are unstable or moving quickly.
• An intensive block, a run of consecutive days of one-to-one work, for people who cannot vanish for a month but can take a week. This is where the four walls get designed in detail, against the specifics of one life.

Frequency is not fixed at the start and does not only go one way. Intensity rises when it needs to and settles when it can.

Where this applies

The model came out of clinical work with eating disorders and applies equally there: an inpatient unit supplies rules, structure, routine and support around eating, and discharge withdraws all four at once. The same argument holds, and the same work follows.

Getting started

The first step is a consultation, which is a conversation rather than an assessment form, and which will include a straight answer about whether outpatient work is appropriate for you. In person in London, or online.

Further reading: addiction counselling and therapy in London, the executive approach to addiction, how to choose a rehab, what happens after detox, and what a safe space means clinically.

Dr Philippe Jacquet is a UKCP registered psychotherapist, a Jungian analyst and an HCPC registered art psychotherapist, with twenty-five years of clinical practice. His Doctorate of Professional Practice at the University of Essex examined male eating disorders from the perspective of analytical psychology. Registration can be checked on either public register.