Addiction is a stress-driven disease. Addicts are impulsive. Their decision making is emotionally driven and poorly thought out. They overvalue drugs and underate the consequences of their relapsing and they cannot see how their behavior negatively impacts the people that they love.
Leaving against medical advice (“AMA”) is defined as the patient’s decision to leave the facility after having been informed of and having the ability to appreciate the risk of leaving without completing treatment. Fully competent patients are legally able to discharge themselves without completing treatment.
Treatment Centers struggle with clients wanting to leave Against Medical Advice (AMA) and sometimes the length of their stay in treatment does not meet the goal of the treatment team. When a client wants to leave it creates a crisis disruption in the program for everyone.
People seeking treatment for substance abuse and addiction are at heightened risk when they leave recovery treatment facilities against medical advice (AMA).
It is crucial for staff to understand why individuals leave and to know how to attempt to block these efforts in a therapeutic way.
This course will explore:
- Who is most likely to leave against medical advice.
- Why do individuals leave against medical advice?
- What are the dangers of leaving against medical advice?
- What can be done to prevent people from leaving against medical advice?
The terms client and patient are used interchangeably throughout the course.
Understanding who is most at risk of leaving treatment against medical advice will help you recognize population prevalence, warning signs, and other factors that can worsen the already deteriorated state of a possible AMA discharge. These issues must always be recognized and interceded upon in order to give the best possible outcome.
Individuals most at risk for leaving AMA include:
- Clients experiencing withdrawal symptoms and detoxification
- Clients with prior treatment failures
- Clients who report little to no problems
- Clients with co-occurring disorders
- Clients who are male and ages 18 to 29
- Clients who isolate
- Clients who are externally motivated
- Clients with significant cultural differences
- Clients who do not engage the family in the treatment process
- Clients without primary care doctors.
- Clients without medical coverage or poor coverage.
Even though certain people may be at higher risk, there is no way to predict exactly who will leave. Instead, it is best for physicians and recovery center professionals to be prepared to assess a patient’s desire to leave and help the patient work through what is a true immediate need, doing their best to calm a patient’s fear both of treatment and of letting go of personal endeavors to undergo treatment.
People leave medical or professional care for a myriad of reasons. Some are legitimate obstacles to treatment and some lean more to the side of an excuse. Treatment and sobriety are hard. Life has responsibilities that are not easily postponed even in the case of needing critical care.
A leading cause for AMAs occurring within the residential setting is trait impulsivity and neurocognitive expressions of impulsivity.
Trait impulsivity has characteristics, such as:
- lack of premeditation
- sensation seeking
- lack of resiliency
- difficulties in coping with strong impulses
Neurocognitive expressions of impulsivity separate into two categories:
- impulsive action
- impulsive choice
Impulsive action is defined more by poor inhibitory control, while impulsive choice refers to a distorted view or inability to see delayed consequences. These are a concern because clients leaving treatment AMA are doing so impulsively.
- Family issues
- Financial reasons: no insurance, insurance which would not cover an extended stay, or a general inability to pay for care
- Personal reasons
In addition, a person may choose to leave rehab because he or she was not initially committed to attending in the first place, feels prematurely capable of maintaining sobriety, becomes overwhelmed by symptoms of withdrawal, or is experiencing an overwhelming urge to use drugs and/or alcohol. Regardless of the reason why, this is a decision that can have far-reaching implications, endangering both the individual’s health and their chance at sobriety.
People who wish to leave facilities AMA may not receive enough care. It is a challenge to provide quality healthcare when patients do not adhere to their provider’s recommendations for treatment. But not receiving proper care at the time of admission is not the only negative outcome of leaving AMA—it also puts people at risk for a number of adverse outcomes, including:
- Higher readmission rates in comparison to people not discharged AMA
- Lack of access and guidance to relapse prevention plans and critical aftercare support and programs
- Failing to understand the full potential of treatment or leaving with a false perception of rehab, due to the fact a person did not have the full
- opportunity to engage in the entire spectrum of care offered
- A false and misleading sense of overconfidence that may lead a person to put themselves in dangerous and tempting situations
- Leaving without the full spectrum of skills rehab can teach
- Failing to learn about the factors that drove them to drug or alcohol use in the first place, thus leaving them susceptible to these triggers in the future
- A person is not fully prepared to maintain sobriety on their own, thus increasing the odds of relapse
- If relapse occurs, an overdose may follow—especially after the period of sobriety experienced in rehab and the possibility of a reduced tolerance from this time
- In the worst possible outcome even death—in some cases overdose may be fatal
As discussed earlier most clients with substance use disorders will have issues surrounding impulsive acts and impulsive choices. Learning to identify, interrupt, and intervene on clients who display these characteristics will not only reduce AMA discharges, but it also may help prevent a rise in readmission rates and relapse occurrences.
Typically by the time the staff intervenes, a client is 90% out the door. Early interventions and reachable goals are a necessity in reducing the possibility of a client leaving AMA and increasing the chances for long term recovery.
The literature is consistent with concluding that patients will signal that they are thinking about leaving AMA before they actually leave AMA. Understanding this requires the providers to “hear” the patient and to have effective communication between all providers. Effective interpersonal communication includes interpreting verbal and nonverbal language.
Understanding the patient’s rationale for leaving AMA will provide opportunities to proactively address the issues.
Recovery produces uncomfortable feelings. As a general rule, people like to avoid being uncomfortable.
One of the most important factors in treatment outcomes is the client’s belief that they can successfully change their behaviors. The quality of the staff-client relationship is a critical component of this belief. In the end, how the staff feels about a client’s chances of success affect the client’s outcome. So the final question is, “Does the client believe there is hope?” For clients to feel hope, they must have movement, and to have movement, clients must have a plan. These plans must be individualized and reviewed with clients weekly to show them their progress or areas of concern. Simply put, clients who experience success will be more invested in seeing treatment through. Clients who do not see improvement will be more apt to quit.
People who are leaving may be worried about personal obligations, such as family or work. Maybe a person refuses to stay because he or she is unsure who will take over these responsibilities when he or she is gone. This may be especially true for patients undergoing inpatient substance abuse treatments whose stays can range from 30 days to 120 days and beyond. Treatment is essential for the health of addicted individuals and working through these worries could be the crucial deciding factor in securing much-needed treatment.
Physicians, nurses, counselors, behavioral technicians, family, and friends in support of a person’s substance abuse treatment may all play a role in helping quell the fears of someone wishing to be discharged AMA. People who enter emergency departments for care due to substance abuse may be panicked from the experience. The support they receive or don’t receive can make a world of difference.
Addiction can also cause people to undergo changes in brain chemicals—many affected by addiction are unaware that their lives have changed to revolve around seeking and using substances. In addition, many substances may impede a person’s judgment and ability to think soundly, while also impairing their capacity to make rational decisions. Therefore, some people may be unaware of or unwilling to see that they need treatment. In these cases, it may be helpful to stage interventions or gatherings of people who care about addicted individuals and who want to show their support for recovery.
Counselors who handle patients at risk of leaving AMA should assess the patient’s fear of staying. For instance, is the patient’s need to leave an immediate one, or is there family who could be contacted to fulfill these obligations while the patient undergoes treatment? Further, does the patient want to leave because he or she is unwilling or not ready to admit to a substance use disorder? If so, it may be helpful to address this with the client. If a person is concerned about their financial responsibility for treatment, staff should spend time working with them on their options, including various scholarships and grants.
Professionals in addiction treatment facilities are in a unique position to help people stay and receive the treatment they need. Substance abuse treatment is not an easy time—from detoxification to the withdrawal process, too early recovery and continued care, those who undergo treatment have a long road ahead of them. It is the reason many enter recovery treatment: to get professional support and monitoring in a substance-free environment. For this reason, it is important that all treatment staff are fully aware of the patient’s concerns, in line with the patient’s treatment plan and goals. This can greatly help towards identifying those at risk while helping to abate their fears and concerns.
Interventions are most successful when the recovery professionals know their population. This reality, coupled with an understanding of why people leave treatment AMA, enables us to implement strategies to reduce the likelihood of leaving AMA.
The interventions used must make sense, be simple, and start before clients ever enter the treatment center.
- Create a culture of watching for the signs
- The admission process and orientation should be thorough so that the clients feel as comfortable as possible and understand what is expected of them so they can process what obstacles might interfere
- Obtain Consents to Release Information upon admissions
- Review AMA information with family and the referral source
- Evening/Weekend Counselors should meet with all new admissions so the clients know who on the unit and when they can be expected to have different staff there
- Create an environment of structure
- Ask clients what they need to support their stay in treatment
- Remain focused. Use clinical skills and client’s input to develop solutions
- Be consistent with the guidelines and hold “Guidelines Group” frequently
- Communicate. Read that again.
- Listen. Read that again.
Let’s look deeper and some of the strategies that can be used.
Preparing The Support System
It can help to talk with patients and their support system about how this will likely come up. Those in a patient’s circle of support need to be prepared for the possibility of the patient coming to them to help them leave treatment.
- Who will make it easy for them?
The staff should understand in advance who will make leaving easy for the patient.
- Reduce the ability to manipulate.
Ensure the phone calls occur with the counselor involved. Explain that it is common for addicts to play on a family’s hope that they are done using; to use guilt and anger and fear to get assistance in leaving.
- Ensure financial resources are limited to necessity.
Utilize the Staff and Therapeutic Community
Staff should regularly assess the client’s risk level for wanting to leave treatment. When a patient is expressing lower satisfaction and motivation work as a team to provide:
- More attention
- More group process
- More individual sessions
- Close off easy opportunities to leave
- Confront impulsive thinking
- Encourage the patient
- Show empathy
- Help them to better deal with emotions
The therapeutic community can also be employed to support the patient. Other residents that might be further along in the treatment can provide support and understanding, as well.
Appropriate Language and Key Questions
When a patient is contemplating leaving treatment against medical advice, they are usually in the mindset prepared to argue, to defend their position. It is necessary to use non-argumentative language with them. The most important piece is to listen to their concerns. Don’t shrug them off. Listening and letting them know that you understand what is pulling at them will go a long way in defusing their resistance to talking with you.
- Don’t ignore the patient who wants to leave AMA. If possible, stop what you are doing and address their concerns and feelings.
- Determine the decision-making capacity of the patient. Do they comprehend the information and consequences and understand the risk and benefits of the options?
- Don’t blame or berate them or anyone else for their desire to leave.
- Don’t just ask them to sign a generic AMA form and leave. This course of action providers little protection for the treatment facility and doesn’t serve the client.
- Talk with the client about their whys for entering treatment through questioning.
- Suggest the client talk with friends or family that were in support of them entering treatment as a means of working out any possible obstacles and gaining support.
- Don’t express your frustration and anger to the patient. Earnestly express to them that your overriding interest in their well-being.
Building Rapport Before, During, And After A Patient Wants To Leave AMA
When trust and rapport are not established, a client tends to be more guarded and resistant to the treatment process. A client should be able to trust the recovery staff and to feel comfortable with the treatment plan. The rapport between the client and the counselor can build the trust necessary for the client to feel like the difficult process of change is both possible and worth it.
Building rapport and trust include genuineness, unconditional positive regard, and empathy. Staff should be truthful and honest, accepting the client but not the behavior, and have empathy for the client’s situation.
This begins with a thorough evaluation and continues through to creating a treatment plan. What are the obstacles that the client is aware of? Are they afraid of losing their spouse or job? Do they have kids or pets at home? Are they concerned about cost or relapse? Not every client has the same obstacles and understanding the concerns of each, individually, can help you understand them as a person. The goal is to gain a clear understanding of the client’s perception of the problem at the deepest levels. Does the client feel listened to? Understood?
Rapport can be established through:
Pay very close attention to the words and emotions of the client, and let them know that he or she is being heard and understood.
Research shows that rapport increases with counselor verbosity. The more you verbally engage the client in dialogue (rather than just listening), the better rapport will be.
Using fewer encouragers
Research shows that encouraging statements such as ‘uh-huh,’ ’yes’ and ‘go on’ do little or nothing for building rapport.
Asking open-ended questions
Who, where, what, when, and how (not why). Open-ended questions will require the client to give in-depth responses that promote dialogue and deepen the relationship.
Emulating the client’s speech
Having the flexibility to use words, phrases, and metaphors familiar to the client is important for rapport building. Listen carefully to the language the client uses, and attempt to adopt some words, phrases, and images the client feels comfortable with.
Finding common ground with opinions or beliefs
To help increase rapport, validate something the client knows to be true, before leading him to consider other possibilities. This is less damaging to rapport than challenging the client’s beliefs alone. Motivational interviewing shows us that the most likely result of too many direct challenges is defensiveness. However, do not compromise your integrity or pretend to believe in something you do not.
Make an effort to slow and soften your conversational approach, and even try to work some humor into the dialogue. This personal touch may go a long way in helping to build relationship with clients.
Have you learned that every time the patient has a visit from their spouse they get upset? Have you recognized that when a new resident arrives they get nervous? Pay attention to the needs to get ahead of issues.
Your client needs to know that you will be a source of stability amidst his or her times of crisis. Make sure you always seem calm and controlled.
The most important factor in reducing the patient’s desire to leave treatment against medical advice is to recognize and combat the signs that a patient is going to want to leave to get ahead of the issue. The second most important factor is to understand the patient’s needs. If a patient tells you they want to leave treatment ask them the key question of:
“What do you need to support your continued treatment?”
We can predict and guess all day what might be motivating the desire to leave. Rather than fixing problems that may not exist, ask the client what they need to be addressed. Engage the patient if being part of the solution.
Handling The Angry and Obstinate Patient
As said before, usually when a client finally verbalizes the desire to leave they are ready for a fight. They have built up the nerve to be direct and confrontational. They have attempted to manipulate family and friends to support their desire to leave. They can be angry and obstinate.
The following are important items to keep in mind when dealing with an angry patient:
Understand that addiction treatment is not easy.
No person would ever want to be in a recovery facility. Counseling and self-reflection can be painful. Addiction causes feelings of being out of control.
As a recovery professional it is your role is to let the patients feel that you understand and care about them. You can show empathy by focusing your attention on your surroundings and to their feelings, expressions, and actions. Show them that you are interested and that they are important.
Allow the patient to calm down
Give an angry patient the opportunity to calm down and have space before continuing your “arguments” for them to stay in treatment. Consider this a process not simply a request.
Do not invade the patient’s personal space
Try not to get either too close or too far from them. Let them feel that they still have their own personal space that you wouldn’t be invading and that they are safe there.
Think about how you would feel if you were in their shoes. Being sensitive to people’s feelings means accepting them and respecting them no matter what happens.
Gentleness is a quality that comes from the heart and soul. People who are gentle establish peace and are strong enough to remain calm and show restraint even when faced with difficult situations.
Think before you respond to anything the patient says. Sometimes, people react too quickly without taking time to think about how their responses might affect others.
If you are to respond, do it in a calm and kind manner. If you want to make the situation better, try to avoid negativity. Instead, focus on something that you can do to help the person.
Do not argue
Trying not to argue doesn’t mean you cannot voice out your opinion. It only means you have to state your point in a decent and respectful manner. Be truthful of everything you say, and try not to think that you are always right. Communicating better and having a positive behavior towards any issue will solve anything.
It may come to a point when you have to set a boundary. Keep yourself safe but let them know that you are listening to them. Defuse situations before they even escalate. A patient has the right to be involved in their medical decision-making, but they cannot use that right for any unreasonable demands.
Communication is one of the most important aspects of the counseling profession. Be honest with everything you say to the patient. Be available and responsive to your patients. Never let them feel that you are ignoring them. It will be much easier to fix things if effective communication is used.
Acknowledge the patient
Validating the person’s feelings will help them feel understood. Let them feel that their feelings make sense, that you hear them and you understand them. People, especially those who are angry, often need to know that you don’t think they are bad or crazy for feeling that way.
Validating a person’s feelings requires a temporary suppression of the impulse to explain your side. Focus your attention on what your patient or their family member feels and try to acknowledge their feelings.
Let the patient speak their mind without interrupting. Listening does not only expand your capacity for empathy, but it also sharpens your communication skills. Active listening also means you should look at the problems from the other person’s point of view. Focus on what the person is saying to you before offering any help.
Ask Open-Ended Questions
Ask gentle, probing questions to learn more about what the other person thinks and feels. Ask for clarifications if you don’t get what the patient is trying to say.
Remember that close-ended questions might make the situation worse because it will only let them feel that you are not interested in what they have to say. Open-ended questions, on the other hand, will show them that you care. Ask them questions like “Why do you feel this way?” or “How do you feel about it?”.
Don’t make defensive responses
Think first before responding. Learn how to pause and breathe. This will calm you down and control your response. It will also prevent unnecessary outburst. Understand that many factors have led to a verbal attack from your patient or their family member. Consider that you may not be the sole reason for their anger and that there is no point in getting defensive.
Use appropriate language
“You are projecting your anger from your biological family on the therapeutic community” will not calm the patient down. It is necessary to speak to the patient in language that is common for them to use and understand. If you try to come off as the expert they will escalate. Choose your words wisely.
Watch your body language
Never cross your arms when facing them and don’t turn your back from them while they are speaking. Maintain eye contact if necessary, just so you can let them feel that you are open to what they have to say. Openness means that you are willing and ready to listen to them without judgment.
Handling Guilt, Remorse, and Self-Sabotaging Behaviors to Avoid AMA
It is not the lack of knowledge, effort, or even desire that causes a client to abandon treatment, but rather the real obstacles such as finances, kids, and jobs as well as the mental chorus of self-dialogue that confuses the issue.
Self-sabotaging behavior includes:
- Lack of personal responsibility
- Lack of awareness
- Poorly communicating with others
- Poor decision making
- Refusal to accept a problem
Helping a client recognize self-sabotaging thoughts and behaviors can make a real difference in them following through on treatment.
- Ask the client what is the payoff for self-defeating behavior? Is it a reason to go back to using? Is it a way to get attention?
- Help the client to avoid situations that trigger extreme emotional reactions. Extreme emotional reactions can provoke a relapse. If you can’t avoid these situations, at least try to get a realistic perspective on them. Ask yourself, “how important is it really?’”
- Help the client to identify the origins of their belief system. Once you have identified where those defeating attitudes came from, let go of them. It is OK to acknowledge the past, but not to use it as an excuse to continue your behavior into the present.
- Assist the client in feeling like they are in control and making good decisions. They are not a victim of their circumstances.
The Process of AMA As An Intervention Strategy
Understanding that leaving against medical advice is a process and not a signature on an AMA form can be one of the best interventions. When a patient states that they are leaving treatment, rather than immediately arguing with them on the myriad of reasons to stay, let them know the “process” for discharging AMA. The process can and should include:
- The request of a specific amount of time such as 48 hours
- An evaluation and documentation of their capacity for decision making addressing
- The patient’s goals and values along with the treatment alternatives and referrals
- Consequences such as risks of refusing and declining treatment.
- Including family and social resources when addressing post-care planning
By beginning a process that takes time and engages the patient in the planning and consequences of leaving treatment you have created the time, without the resistance, to help the client re-establish the desire for treatment and reduce the reason for wanting to leave.
Simply because a patient elects to leave AMA does not mean that he or she is always entitled to do so. In fact, there are situations in which the counselor is mandated to override the patient’s refusal to stay (i.e., not permit a patient to leave AMA), such as when the patient is: expressing suicidal ideation, lacks decisional capacity, or is a danger to others.
Some facilities require specific documentation when a client is leaving against medical advice. Research has suggested though that these forms create an adversarial relationship and are not protective against liability. Be aware of whether your facility utilizes these forms or not.
When faced with a patient requesting to leave don’t refuse to provide treatment, this could be considered abandoning the patient. Provide whatever treatment, follow-up appointments, discharge instructions, and referrals the patient will accept and document these in the patient’s chart. Document all details of the AMA discussion, as well. Include the documentation of the patient’s decision-making capacity, the specific benefits of your proposed treatment and risk of leaving AMA. Document what you did to attempt to get the patient to stay in treatment as well your expressed interest in the patient returning to treatment at any time. If your facility uses a form have the client sign it with a witness.
Some examples of documenting in a client’s chart:
- The patient has decided to leave against medical advice because ______.
- They have normal mental status and adequate capacity to make medical decisions.
- The patient refuses treatment and wants to be discharged.
- The risks have been explained to the patient including, _____________, worsening illness, relapse, etc.
- The benefits of admission have also been explained, including the availability and proximity of caregivers.
- The patient was able to understand and state the risks and benefits of treatment.
- The patient had the opportunity to ask questions about their health and treatment.
- The patient was treated to the extent that they would allow and knows that they may return for care at any time.
- Follow up has been discussed and arranged with ________________.
Staff should be familiar with the AMA forms their facility chooses to use.
Leaving AMA When Intoxicated
The patient does not have the capacity to provide informed refusal when intoxicated. Diagnosis of intoxication is determined by the legal limit of intoxication in the jurisdiction and not by observation. Capacity refers to an assessment of the individual’s psychological abilities to form rational decisions, specifically the individual’s ability to understand, appreciate, and manipulate information and form rational decisions. If the physician evaluates a patient and determines that the patient lacks capacity, then the patient is referred to as de facto incompetent, i.e., incompetent in fact, but not determined to be so by legal procedures. Competency is a legal term and is determined by a court. Competency is a broad concept encompassing many legally recognized activities, such as the ability to enter into a contract, to prepare a will, to stand trial, and to make medical decisions.
Competency refers to the mental ability and cognitive capabilities required to execute a legally recognized act rationally. The patient does not have the capacity to provide informed consent or informed refusal/declination when intoxicated. As stated above, the diagnosis of intoxication is determined by the legal limit of intoxication (known as legal intoxication) in the jurisdiction and not by observation. However, alcohol tolerance is individualized. A person who has a long history of using alcohol may have a high tolerance level and not be clinically intoxicated at the same time that they are legally intoxicated. This should be documented, but because the patient is legally intoxicated, the patient does not have the capacity. If the patient’s blood alcohol level is under the legal limit but appears clinically intoxicated, this too should be documented and considered when making a capacity assessment. It is possible to not be legally intoxicated and not have decisional capacity. The universal question related to leaving AMA when intoxicated, but not at the legal limit of intoxication is, whether a patient who has been assessed to not have decisional capacity can be held against their will. Many times, this category of the patient (known as clinically but not legally intoxicated) will not meet the involuntary commitment requirements. In these cases, there may be a different route to provide a temporary legal/medical hold for a patient who may be a danger to themselves or others or who may not appreciate the risks of leaving AMA. The treatment or observation plan should be clearly articulated in the hospital policy and procedures.
• Talking with the patient and asking if they would be willing to remain hospitalized until they are clinically sober
• Recognize that there is poor correlation between degree of intoxication and the patient’s clinical presentation
• Document the psychomotor and cognitive impairments
• Document the blood alcohol level
• Determine whether the patient will need to observed until they are below the legal blood alcohol limit and/or are clinically sober
Clients rarely leave treatment because of what the facility staff does. More importantly, clients will most often leave treatment early for what facility staff is not doing. Learning to identify, intervene, and create a culture of prevention is required to be successful in reducing the impulsive decision to leave treatment AMA.
At the core of preventing and reducing AMA discharges are the underlying need for all clients to feel accepted, that they belong and that they have become competent about the disease of addiction and the recovery process. Understanding this and applying the above-listed interventions can lead to successful retention of clients in the residential.
If a patient cannot be stopped from leaving care AMA, professionals should be certain individuals are leaving with informed consent and have been given ample opportunity to ask questions regarding their health conditions. In other words, a patient being discharged against medical advice has to be mentally sound to make the decision to leave. However, before a person gets to that point, there are some things the addiction professionals can do to help them choose treatment instead.
- Know your state involuntary commitment laws and regulations
• Know your state duty to warn laws and regulations
• Anticipate that patients may want to leave AMA
A person may have serious motivation to stop using or drinking, but that doesn’t necessarily mean they remain motivated to do the challenging, frightening, difficult work that treatment necessitates. Facing their past, facing their sadness, facing their 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 their brains are working against them. Drug and alcohol use have been related to deficits in the ways the brain processes information and emotions. An addict will react to negative events and emotions more than they react to positive ones; the good things just do not hold as much weight as the bad. They are impulsive and have a hard time planning. Immediate rewards seem much more important than rewards that could be greater but are farther away. Logically, they 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 they are uncomfortable or upset.
When the patient takes all of this into account, it makes perfect sense to want to leave. As recovery professionals, we know that the moment may come where a client says, “I can’t do this.” We must ask is there anything we could do differently? Is there any way to make the process more comfortable?
When a patient leaves AMA it is a heart-breaking outcome because we know that the best predictor of treatment success is the length of time in treatment; the longer someone stays, the better their chances of staying sober. One of the hardest reasons for leaving to hear is also one of the most honest: “I’m just not ready.”