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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