Supporting Successful
Treatment
This is what I know after more than 30 years of working in the field of
alcohol and drug treatment. Today, treatment outcomes can be
dramatically improved with only minor changes in the treatment
process. If this is true, why haven’t these changes already become a
part of most treatment programs?
There are several reasons for this
and I want you to know all of the facts. When you understand all of
the reasons you will be able to increase treatment effectiveness for
the one you care about. Lets start with the original and most
significant organization to change our understanding about
substance dependence. Why, because it is the model for every other
“12 Step” program.
Until the emergence of Alcoholics Anonymous in
1935 the only approach to changing a person's uncontrolled
use of alcohol was either religious vows or pledges to
remain abstinent, counseling, or personal determination to remain abstinent.
There was limited success with these approaches. Estimates of
success ranged from 2 to 5 percent; horrible odds when your life
hung in the balance.
With the
emergence of Alcoholics Anonymous in 1935 in Akron, Ohio the
recovery rate advanced five fold. Within a decade some of the most
“hopeless” alcoholics where no longer drinking and were returning to
productive lives. The difference appeared to be the refinement of
the spiritual process of humility, supplication, and mutual support
within the members of the group.
Alcoholics who sought
help - asked
for it - were accepted at face value as needing help and were
included in the group. The organization was informal, highly
individualistic but pragmatic. Members offered support based on “this is what
worked for me”. Sharing experiences within the group, particularly
with newcomers, provided benchmarks for everyone about how
changes happened, what progress might be expected, and finally examples
of what life was like when sober and if drinking resumed. Sobriety
was the responsibility of each individual. Everyone had to do the
work on his own recovery. But, sharing about their efforts made a critical
difference in the outcome.
The book “Alcoholics Anonymous”
was a collection of the principles, practices, and
experiences of the initial
group of AA members. It was a
“cookbook” that laid out their collective positive changes and gave
some order about how to start a new way of life. Staying sober was
paramount. Everything else was secondary to that goal. Employment,
family relations, marital status, and obligations of parenthood were
secondary to the overriding necessity to remain sober. If sobriety
were not maintained, all other gains would be temporary and the
decline towards further failure, unpredictability, and catastrophic
loss would continue.
Members of the group knew, as few outside
the group ever knew, the absolute importance of avoiding the first
drink. On that one, personal goal everything else depended. For each
member everything hung in the balance. It was all or none. You were
sober and had a chance of restoring yourself to a better life or you
were drinking and would continue to lose all that you held dear.
This tightly defined measure of success would affect the practices
of alcohol treatment for the next fifty years.
Alcoholics Anonymous changed expectations about
the inevitable outcome of the disease. It provided a body
of evidence that the condition was treatable. It was proof that
long-term change was possible. It is important to note that the
founders of Alcoholics Anonymous developed an organization that
stressed attraction over promotion. (What does this mean?) It means that they believed that active
alcoholics could not be forced to remain sober and that an
individual’s decision to “go to any lengths” was a necessary part of
the recovery process. They would work with alcoholics who sought
them out, but would not pursue or coerce alcoholics that resisted
coming to them.
Waiting for
individuals to “hit bottom” was difficult. Medical professionals who saw the revolving
door of abstinence \ relapse \ abstinence \ relapse began to provide
treatment that stressed the inevitable consequences of the disease
and included exposure to Alcoholics Anonymous support. Treating the
dangerous and potentially fatal suffering of withdrawal and delirium
tremens was the first step in treatment. Combining that medical care
with information about the disease and an introduction to Alcoholics
Anonymous became the “Minnesota Model” for treatment. It increased
the chances for positive outcomes to as much as fifty percent.
Providing
information about the disease (and that information accumulated over the
years) provided a better understanding about the physiological and
psychological changes that accompanied the progressive effects of
the disease. This information increased an individual’s motivation
to complete treatment and continue recovery activities as part of
their post-discharge planning. This meant the protective environment
of the treatment center was partially replaced with exposure to
community-based Alcoholics Anonymous meetings prior to discharge.
Most counselors working
in treatment centers were recovering alcoholics who had time and
experience in recovery. Many had years of service in Alcoholics
Anonymous providing help as sponsors to other AA members or were AA
volunteers who carried the message of hope and recovery on 12 Step
calls. They had first hand experience, gratitude, and an
understanding of the disease from an insider’s perspective. The
treatment field could not have developed the practical, trusted
approach to treatment without them. They personified credibility.
Their
experiences also meant
that treatment providers as a group had an extremely varied background. For
most, being a treatment counselor was a second career based on personal
experience in recovery. Initially, there was no formal training for
individuals wanting to enter the field beyond a desire to become a
counselor and a period of sobriety that demonstrated stability and
recovery. A counselor’s best sense of what worked best was what
worked for him. Counselors realized the grim outcome of the disease
and realized that their recovery process was an unfolding miracle.
As the field developed, training and certification was instituted as
a means to provide some standardization across the treatment field.
This was a necessary step in unifying treatment practices beyond the
application of personal recovery experiences.
An
accompaniment to this certification process was the increasing
addition of professionally trained individuals who had not
experienced alcoholism or recovery. It took some period of
adjustment for the treatment field to integrate the strengths of
both backgrounds into treatment practices.
Added to this
adjustment was the explosion of individuals addicted to drugs or co-addicted to drugs and alcohol.
Drugs proved to be more than just an additional substance that could cause
addiction. Their speed of progression in some cases was like an
express elevator into complete destruction. And there were problems
among the treatment practitioners. Confusion about how to work with
the younger, drug involved clients tended to split opinions about
what to do. Many of the older, AA oriented counselors did not have
the usual life experiences to guide them. Many of the recovering
drug addicts entering the field did not have the length of recovery
and stability to guide them. Each group had skills to offer but it
was more than a decade before they could move to common ground about
how to provide treatment. As the age of clients entering treatment
kept dropping and the speed of some addictions kept accelerating,
treatment became more challenging. The task of rehabilitating adults
who had lost some or most of their adult life skills was being
replaced. Now, the task was to teach younger adults and teens, life
skills they had not lived long enough to develop in the first
place.
As vital life-skills were identified
and added to the increasingly long treatment plans, some dilution of
focus was bound to happen. Occasionally it took the form of near
chaos. The educational portion of the program was enlarged to
provide information on the ever-expanding list of dangers of the
newest drugs as well as preventive efforts to discourage use of
drugs that had not already been tried. Educational programs,
occupational testing and activities, psychological evaluations,
recreational activities, confidence builders, family reunification,
parenting skills, anger management, violence prevention, AIDS
testing and prevention, STD testing and prevention, medical
treatment, and positive health habit development were all emphasized
one after another. In addition, insurance companies and HMOs
demanded the most effective treatment, in the least restrictive
settings, in the briefest time possible. It was a set of
expectations that rocked the treatment field. Many programs were not
able to satisfy all of these competing demands and closed their
doors.
Providing
treatment requires a well-defined flow of events for the most efficient delivery of services.
This system has to answer multiple needs. Some are internal to the
provider - patient schedules, group topics, patient treatment
sequences, quality improvement tracking, staff schedules, marketing,
etc. Some are external requirements - fulfilling licensing
requirements, negotiating contracts for services, paying for
buildings, utilities, malpractice insurance, etc. And some are based
on client needs - timely intake process, matching treatment needs
with available services, referral agreements for unmet needs, family
support and education, etc.
These
needs are not mutually exclusive
, nor are they in complete competition. They are prioritized
however, by a sense of relative importance on an ongoing basis. Let
me give you a few examples. If the fee for service that the program
receives has not increased for two years and the program had planned
to develop a comprehensive family problem, the family program may be
deferred until there is an increase in the contract. In the same way
plans for a women’s tract, a relapse tract, a poly-addictions tract
may be put on hold until a means to pay for the additional treatment
can be guaranteed. Before extra staff with specialized training can
be hired, a way to pay for the services has to be set in place. This
doesn’t mean that the program doesn’t care about its services but it
does mean that financial considerations do affect the quality of its
services.
Programs have
responded to this array of priorities in different ways.
Some have developed specialties such as dual diagnosis treatment or
women with young children programs. Some have focused on maintaining
the lowest possible costs. Some have left the insurance/HMO market
and depend on affluent self-pay patients. Some have become
grant-funded programs. All of these options or combination of
options affect day-to-day operation. It also affects the “mindset”
of what is normal procedure in that organization. Staff members
approach the client’s treatment with a set of understandings about
the program’s system of treatment. Usually they do not approach
client problems with “outside of the box” thinking. By standardizing
the approach to treatment the staff and the program are able to
increase their internal efficiency.
What does this mean? It means several
important things. It means that when staff are filling out intake
forms they only ask those questions that are on the form. Usually
there is no additional space on the form for added information and
if the client volunteers more information it is usually left
unrecorded. That doesn’t mean it is forgotten - it just means that
only one staff member knows that particular information. It may or
may not be verbally passed on to other treatment
staff.
It also means that the program has a series of topics that are
pre-selected for use in group discussion. The topics rotate in
sequence. If a client remains in treatment for an expected length of
time he or she will be exposed to all of the topics at some point in
treatment. But, even though a particular client knows and
understands 50% of the topics on the discussion list because of
prior treatment experiences and needs extra help with three of the
topics, he or she will be required to attend all of the groups in
sequence. No missing some groups and extra work on the other three.
Why, because there is a system in place that fosters the most
efficient presentation of group discussion for the greatest number
of clients and this is what gives the program its “economy of
scale”.
Economy of scale is the formula that defines the client to
staff ratio. It is calculated to allow the staff to complete of all of the required
tasks for each client. Keeping to that ratio
means that income and costs are in the best balance. Having the
number of clients below that ratio means lost income. And having
that number above the ratio means the staff cannot complete all of
the required tasks. Economy of scale is vital to remaining in
business.
All of this
affects clients in treatment.
No program can
meet all of the conditions I have gone through for every single
client and satisfy them in the client’s best interests. It is
impossible. Don’t expect it to happen. Instead, go back and look at
all of the conditions I have briefly listed here and then go through
some of my other articles and create a checklist of treatment needs
for the person you care about. The program has to satisfy a lot of
competing needs. The program is not going to focus its entire
process on the needs of the one person you care about. So, you need
to become the advocate that is solely and completely focused on that
one person. You have the advantage of standing back and reviewing
what is being done and comparing that to what remains to be done.
Make sure the treatment staff knows about your checklist and your
tracking process. Work together to establish the sequence that will
be followed.
Don’t let important needs fall through the
cracks. You don’t
direct the treatment, but you make sure that treatment meets the
needs of the person you care about. You have to be as well informed
about treatment and the needs of the person you care about as the
staff who are providing that treatment.
If you are seeking treatment
or are planning
to support someone who needs treatment, please use this information
as a guide to information about treatment. Be sure to check the list
of articles for other useful information that applies to the ongoing
stages of treatment and recovery. Please check back soon because new
articles are being added weekly.
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Copyright © Stephen Buchness 2005