June 17th, 2010 by restoringsanity.com
What Would Treatment for
Alcohol and Other Drug Disorders Look Like
If We Did It Right?
Note: This site addresses treatment design issues for people working in the field. If you are seeking help for yourself or someone else, here are some links you might want to try:
SAMHSA Treatment Facility Locator
The Alcohol & Drug Addiction Help Information Center
Other Addiction Resources
Contents of This Website:
Two Treatment Priorities:
- A Dynamic Community Interface
- Recovery-Based Case Management
- Housing and Shelter Options
- Acupuncture
- Urine Monitoring
- E-Information and Community
- Mental Health Services
- Medical Services
- Individual, Couples, Family, and Group Counseling and Education
- Vocational Services
Coming Next:
Staffing, Volunteers, Organizational Issues, and Training
The Manual
Client-Centered / Recovery-Based Treatment for
Alcohol and Other Drug Disorders:
A Best-Practice Model
© 2010 by Alex Brumbaugh
Preface
What would treatment for alcohol and other drug (AOD) disorders look like if we did it right?
The design model that follows is not determined by cost, nor influenced by what services are currently or even potentially reimbursed. It is rather a description of the conditions and elements which are both necessary and sufficient(1) to bring about successful, sustainable, long term recovery from AOD disorders.
AOD treatment has long been a creature of funding, bobbing like a cork on the fiscal sea of political whim that dictates what modality is “in” or “out,” what addicted population is a priority to treat this season and which one is not, and which “latest research” study has caught the attention of a politician, funder, or administrator.
It is as though treatment as a field has lost its center – has come to doubt its own roots and its own experience. Treatment programs have sometimes become as sick as their most enmeshed clients, allowing other people to write for them their own life script.
The field has therefore often fallen into a culture of poverty. It may preach to its clients to empower themselves and embrace all that they can be and to go forth and flourish, while the program itself languishes, perennially underfunded, in a state of resigned neediness.
Hip surgeons don’t do that. Hip surgery costs what it costs, both in the acute phase and the rehabilitative phase. One would be surprised to hear hip surgery professionals describe their best practices in a context of limited resources. They don’t stay, “Well, if we had the funding, we could keep people on crutches a couple of weeks longer.”
It is time for AOD treatment to come of age. We need to stand tall with what we know, and become empowered to say, “This is what it looks like when we do it right, and this is what it will cost.” If we value ourselves and our work to that degree, it might become realistic to expect that our work will be properly valued by the communities we serve, by government agencies, the insurance providers, the private benefactors.
The integrated treatment model that follows is based on a combination of experience, evidence, and common sense. It will have derived from – and be a synthesis of – those who contribute to this conversation through papers, emails, or comments. (See “Call for Papers”)
We have called this model the Client-Centered / Recovery-Based (CC/RB) Model©. The model is not intended for adolescent populations nor for use in an incarcerated setting (though it contains elements that have been successfully used in those settings).
Outpatient Sobriety
This is a model for outpatient treatment. Our optimum design has a residential detox opportunity, and clients may be housed in adjunctive sober housing or other group homes while enrolled in the program. But one of the operating principles of our treatment program is that our interventions will be the least invasive as possible. People who live in a situation that does not pose significant barriers to successful recovery should remain there and come to treatment on an outpatient basis.
In order to meet our goal of successful long term recovery, we need to be able to retain people in treatment in spite of use episodes or relapse. Our program will be “user-friendly” in the sense that use episodes do not result in treatment discharge or drop-out. Residential treatment programs cannot easily tolerate relapse because the clean and sober environment has to be maintained for the benefit of all residents. Our model will provide support necessary for people to achieve long-term sobriety in the community in which they live. Clients for whom living at home poses threats to early recovery can be housed nearby the treatment program in shelters, gender-based sober housing facilities, or other transitional group homes. The treatment program may or may not be in the housing business, but the formal treatment program needs to be independent from the place where people sleep and eat.
The primary function of the residential detox will be to provide supportive housing for those for whom a use episode has resulted in loss of their residency in another type of group home. Most of our clients will detox on an outpatient basis.
Our optimum program has the flexibility for providing “step-wise” or phased treatment plans from intensive day services to low intensive outpatient. Most services also need to be available seven days per week, because weekends are a high stress time for many – especially in early recovery. Some surveys have shown that over 70% of people who need AOD services are in the workforce, so our services need to be flexible enough to accommodate people who work a variety of schedules.
Assumptions
There are a variety of ways to organize services in an AOD treatment program or agency. The way in which services are organized usually depends on external factors such as funding or on internal design preferences – conscious or unconscious assumptions about where the locus or successful recovery lies, and about what factors are most important for successful long term recovery to occur.
For example, does successful recovery depend upon living in a safe and sober environment? Does it depend upon another drug, used as replacement therapy? Does it depend upon the cultivation of a relationship with a therapist or counselor? Does it depend upon the client’s fear of the consequences of relapse? Does it depend on successful vocational rehabilitation?
Which of these – or which combination of these – are necessary and sufficient to bring about successful, sustainable, long term recovery? How the program answers this question is important because it will provide the focus for and color the conversation between the client and the program from the very beginning.
The truth is that all of the factors mentioned have a role in successful treatment and recovery. But the core assumption upon which we will base our model is that the foundation of successful recovery lies (a) within the person themselves and (b) with natural recovery supports in the person’s environment.
That is why we have called this model the Client-Centered / Recovery-Based Model.
(1)We paraphrase here and in later sections an article Carl Rogers wrote in 1956 called “The Necessary and Sufficient Conditions of Therapeutic Personality Change”
Client-Centered Services
May 10th, 2010 by restoringsanity.com
Our first premise is that the model program be client-centered.
Carl Rogers
The “person-centered” or “client-centered” concept – introduced in the field of psychotherapy by Carl Rogers in 1951 – was part of a revolutionary movement to get the Freudian therapist out from behind the desk, and to get the patient up from the couch in order to assume a measure of responsibility for the work of therapy. Few diseases require for their recovery or remission more responsibility and involvement on the part of the patient or client than addictive disorders.
In his client-centered model, Carl Rogers developed a style of therapy that was characterized by active listening, accurate empathy, genuineness, and spontaneity. These are all good things, especially in AOD treatment. But beneath the process was the important philosophical belief that the client had the inherent capacity to move toward healing. The agenda in the therapeutic process was the client’s, not the therapist’s. There was unspoken faith that the client’s agenda was immanently valid. The therapist’s role was to provide a safe container in which to cultivate and follow that agenda rather than to impose his or her own.
In client-centered therapy, all of the interventions are organized around that belief in the person’s own ability and willingness to move toward healing.
Such a belief is sometimes hard to sustain in the day-to-day world of dealing with chronic alcoholics and addicts. Their agenda does not always appear to be one of healing. Their agenda often appears instead to be one of getting as far away from the treatment program as possible and getting loaded!
But if they were completely honest with themselves, what would they say that they really want?
Addiction is a disharmony, an imbalance. The anthropologist Gregory Bateson said that “The agenda of the body is always balance.” Feeding an addiction is actually an attempt to restore balance and harmony, but it is fighting fire with fire. The state of intoxication may provide a moment of a sense of restored harmony and balance, but it is short-lived, a transitory state, chemically induced, and – due to neuroadaptation – a downhill slide.
Beneath the rage, beneath the fear and anger, beneath the hopelessness, beneath the denial, beneath the arrogance and drama and self-obsession that often characterize our client’s exterior state, there is another client – the “client within” – one who would love nothing more than to find a solution, to find a way out of the darkness, to find a way of putting the drugs and alcohol behind them once and for all and getting on with their lives.
The successful treatment program embraces a belief in the existence of that inner client, the client who craves authentic balance and healing, who seeks a restoration of harmony and of sanity.
That is what the client really wants – If they could only find a way to do it!
It is to that inner client that our program speaks and responds with clarity, confidence, and hope, and around whom it organizes its services.
It is far easier – and sometimes seems more natural – for the program to focus on the consequences of the client’s addiction (the drama that brought them to treatment) or the substances to which they are addicted. These issues are seductive. They certainly appear to be the client’s focus of attention, and they seem to demand the attention of the program as well. It is harder, and requires more discipline and attention, to focus on the glimmer of hope for recovery that lies within.
Indeed, for some, recovery itself means hope. And the second premise of our “Model AOD Treatment Program” is that it be Recovery-Based.
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Priority #1: Maintaining a Welcoming Culture
May 10th, 2010 by restoringsanity.com
We propose two priorities in the model treatment program.
The first is maintaining a welcoming culture.
Addiction is a culture. Twelve-Step and other peer- and faith-based recovery models work because they also comprise cultures, with their own language, symbols, rituals, roles, and activities. These recovery cultures engage and transform the alcoholic/addict and become a way of life independent of formal treatment interventions that may have precipitated their induction into that culture. (White, 1991)
Treatment is a bridge between cultures. It is about helping to facilitate a transition from one culture to another. Its purpose is to attract and engage people in activities that will allow enough stability for them to safely reach the other side.
Not to mix metaphors, but the treatment program is also a beacon announcing a safe harbor – it needs to shine bright. People need to feel okay about being there.
They don’t need to feel elated about being there, or even good! That would not be a realistic expectation, because not only are they being asked to extricate themselves from a culture in which they have defined themselves for a long time, but they are also in the pain and discomfort of withdrawal from the drugs they have been using. They are also having at least one other crisis going on in their personal lives – the crisis that brought them to treatment.
The challenge is to make them feel okay enough about the program to come back tomorrow.
Some programs hedge on making new clients feel welcome. They want to avoid making new people feel too special. They are afraid it might feed the person’s ego, which is perceived as a premier barrier to recovery. That may be a hangover from the days of confrontational therapy, or it may be a projection on the part of the program. Whatever the reason, it is not well-founded. When someone new walks through the door, the program ought to roll out the red carpet, drop everything, and bring out the bells and whistles and party hats!
This can’t be overdone.
The reason is that it will have been the most important day in the life of some of those new people, and since we don’t know for which ones, we need to welcome them all with the same jubilance, just in case.
“Mandated” vs. “Voluntary” Clients
It is safe to assume that every client who walks through the door of an AOD treatment program has had some crisis in their lives that has precipitated an attempt at recovery. Being Client-Centered, the program shouldn’t discriminate on the basis of the particular consequences that brought the person to treatment.
That precipitating event is the most profound and dramatic thing going on in their lives. It is also incidental.
The program should not endorse the drama in which the client is currently enmeshed. The client, if successful, may one day view this crisis as a good thing, even become grateful for it. The program should celebrate the client’s arrival without regard for the precipitating factors. If we are successful at welcoming them, there will be plenty of time for in-depth assessment and appraisal of all of the barriers to recovery in their life, and that is where our resources will be dedicated over time.
Nor do we need to commence that assessment on the first day, or even in the first week. Our program design will allow time to develop trust, to let people get settled in and stabilized before we begin invasive questioning about their personal lives.
Some programs create distinctions between “mandated” clients and “voluntary” or “self-referred” clients. Such distinctions are generally neither accurate nor meaningful. There may be specific reporting requirements based upon a referral source, but that is an administrative concern, not a clinical one. The “criminal justice” client is one who got caught. Likewise, because someone is there as the result of problems at work rather than because of problems with her spouse doesn’t mean she won’t benefit from couples or family counseling.
Sometimes programs begin to take on the attitude and demeanor of the agencies who refer most of their clients – like chameleons. They think because nearly all of their clients are referred by the Parole Department, for example, that they have to act like Adjunct-Parole Officers (which endorses the client’s likely projection).
Let the referring agencies do their jobs, and let us do ours.
It is also worth noting that any client who appears keen and enthusiastic about beginning AOD treatment is probably not being truthful, nor is the one who says that they have no choice and are being forced to come. The latter client may not feel like they have a choice, because there are perhaps dire consequences of non-compliance. But unless they are in an involuntary setting, they made a choice to walk through the door and to attempt recovery. That choice needs to be acknowledged and honored. They could be a hundred other places instead.
The important thing is that the “inner client” has arrived, has chosen to attempt recovery, and the question is, what will we do to welcome them and celebrate that event?
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Treatment Priority #2: Forestalling Relapse
May 10th, 2010 by restoringsanity.com
Everything the optimum AOD treatmnent program does after welcoming the client ought to be about forestalling use episodes and relapse.
Relapse and how to respond to its occurrence is one of the most difficult and charged aspects of addiction treatment.
First, we will assert that for our clients who have a history of chronic AOD use, and for whom that use has resulted in significant areas of dysfunction in their lives, abstinence from alcohol and all non-prescribed psychoactive drugs is a goal.
People for whom abstinence is not a goal – people who need only to learn to drink more responsibly, for example – should already have been identified by our staff and referred to moderation management programs or other appropriate options.
We will not subscribe to the assumption that relapse is inevitable. And all of our services will be primarily dedicated to its avoidance. But if it happens, we want to do everything that we can to assure that it is not catastrophic –that clients be retained in treatment in spite of any use episodes.
Addiction is, as has been often said, a disease characterized by relapse, and if we can’t retain people in treatment during relapses, then we are not realistically responding to the disease.
One of the problems with relapse in treatment is how to talk about it. Do we tell clients that addiction is a disease characterized by relapse? If we do, maybe they will get stressed out and relapse twice! Do we tell them that we hope they don’t do it? The problem with that is that if they subsequently relapse, they will probably not come back for fear that we will be disappointed that they relapsed because we told them we hoped they wouldn’t.
Many programs – because it is difficult to talk about – ignore it, and then when it happens, the client simply stops coming and eventually gets administratively discharged.
We are going to dedicate significant attention and resources to this subject, beginning with the exercise of changing the way we think about it. Instead of using the standard phrase, “preventing relapse,” let’s try “forestalling relapse.”
That sounds a little frightening, as though we are granting tacit permission for them to go out and get loaded.
But consider this: We should strive to operate our client-centered program in real time. That is the time frame of our clients. They live in the present. The past is too painful to contemplate, and they may not yet be able to see a path to the future. Personal history is shrouded in fog, and they are not yet adept at setting realistic goals, and they lack clear awareness of the consequences of their actions. They are in discomfort, and they want to feel better – not tomorrow, but right now. Now is what they have.
“One day at a time” is not a philosophy; it is a description of the rate at which time passes. The reason that it is such a helpful construct for many in recovery is that it mirrors the real time, present-moment orientation of the addict or alcoholic. Drugs operate in the present. Treatment needs to do that too - ”replacement therapy.”
For someone who is struggling daily with sobriety, the notion of forestalling relapse is a far more spacious and present-time one than is relapse prevention. “Prevention” is future-oriented. “Forestalling” operates in the present.
The desired attitude is, “I may use tomorrow, or next month, but I think I might be able to make it today.”
Is it not all we can hope for, after all, that they not drink and use today? Would it not be presumptuous to imagine that we could come up with strategies that would prevent them from using alcohol or other drugs forever?
This notion will probably be met with argument. I welcome the dialogue. We will have a lot more to say about it when we get to the actual treatment components as to how we are going to address relapse. I propose in the meantime that we try the concept on for size and use the term “forestall” rather than “prevent” just to see how it feels.
The question then is, besides the things we have talked about so far, what matters more than forestalling relapse?
Well – at the risk of repeating ourselves – lots of other things seem to matter more: applying for disability, finding an apartment, getting a job, getting the teeth fixed, getting a physical, stopping smoking, going back to school, getting a GED, breaking up with the guy, getting a car, getting some more bus tokens, getting a new watch, making it home for Thanksgiving.
And so on.
But the larger reality – and the central assumption that lies beneath all of the things that go on in the optimum treatment program – is one that we have already asserted: if the person can avoid resuming AOD use, everything else is probably going to get better, and even eventually become manageable.
All of the “everything else” – as we have also suggested – is seductive, and because it is, it places the program at ongoing risk of “mission drift.” As a function of their denial and avoidance, many clients will try to engage us in the ancillary issues. They will try to change the subject away from that which is primary.
The program needs to change the subject back again to the clients deeper agenda of getting and staying sober.
If you have an alcoholic who is homeless, what you want is a homeless, sober alcoholic. Then the goal of housing will become more achievable and meaningful. If you have an alcoholic with a bad back, what you want is a sober alcoholic with a bad back. Then you can begin to assess realistic treatment strategies.
So it is important that the program keep the focus on its primary purpose. Recovery always comes first. It is the foundation. That is why everything the program does is about forestalling relapse.
And yet it has to pay attention to the “everything else” because “everything else” includes all the things which – unaddressed – can cause relapse!
All things thus far considered, we can see that will need to be very sophisticated about what causes relapse, and about how to monitor and respond to those things.
What does cause relapse? Terence Gorski identified over fifty-some symptoms or conditions that predict relapse. While his work is a great contribution to the field, we will adopt a simpler framework for understanding the issues that predict relapse based on the work of Dr. S. Alex Stalcup, M.D. of the New Leaf Treatment Center in Lafayette, California.
Stalcup’s first premise is that relapse is preceded by craving, and that craving is caused by stress.
What causes stress?
For the recovering AOD client, there are four circumstances that can cause stress:
-
They are still in withdrawal.
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They have an untreated physical or mental health condition.
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They are living in a stress-inducing environment.
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There is a stress-inducing upcoming event in their life.
Two or more may be happening at once.
To expand on these four conditions:
1. Withdrawal
The acute withdrawal phase lasts from seven to 21 days, depending upon the drug(s) and the frequency and intensity of use. This is a time of very high stress, hence of high risk of relapse.
Following this period is the post-acute withdrawal phase, characterized by (also stressful) cycles of depression, anxiety, craving, and often sleep disturbances that can last weeks and even months into sobriety.
2. Untreated physical and mental health conditions
AOD disorders often result from situations in which people are using substances to mask other disorders, such as chronic back pain or migraines, or mental health conditions such as PTSD, anxiety disorders, or other mental illness.
3. Stress-inducing environment
Clients may be living with people who are still actively using alcohol or other drugs. Or people may be constantly calling or contacting the client to sell or buy drugs. The client may be in an abusive relationship, or work in an environment that would be stressful to anyone attempting recovery, such as bartending, cocktail waitressing, clerking in an adult book store, playing in a rock band, etc. Or they may simply have an overwhelmingly stressful job.
4. Stress-producing impending events
Typical events include upcoming family gatherings (especially weddings or holiday celebrations or funerals), court appearances, the release from custody of a mate (especially one with whom the person used to use substances), etc.
It is absolutely necessary that the program have comprehensive and specific ways of monitoring and responding effectively to these four things on a daily or even hourly basis. We will need to create an environment that is rich in information about how our clients are doing in all of these concrete ways, and in which feedback is immediate and effective.
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A Treatment Hierarchy of Needs
May 10th, 2010 by restoringsanity.com
© 2010 by Alex Brumbaugh
To add perspective to some of the issues discussed so far, let’s borrow Abraham Maslow’s “Hierarchy of Needs” and adapt it to AOD treatment.
Maslow proposed his Hierarchy of Needs in a 1943 paper “A Theory of Human Motivation,” and subsequently described it in more detail in his book Motivation and Personality (1954, 1970). The Hierarchy is generally portrayed as a triangle or pyramid, with the lowest and most fundamental levels of human need at the bottom:
We are all Different, and All the Same
Among Maslow’s insights is that while everyone is unique, we all have certain basic needs in common. The higher levels of the pyramid, the more we are unique; the lower down the scale, however, the more our needs are the same. We all need food, air, water, and so on.
Maslow called the lower four levels of the pyramid “deficiency needs.” If these deficiency needs are not met, the result is anxiety and stress. Moreover, one must meet the needs at each of these lower levels in order to be free to meet the needs at the next highest level.
It is hard to pursue employment, for example, if you are starving.
Addiction Destroys Lives from the Top Down
In a discussion of Maslow’s hierarchy, the addiction counselor and educator Delbert Boone (2002) has pointed out that alcoholism and drug addiction destroy the life of a person beginning at the highest levels of this pyramid and then moving down little by little as the disease progresses, until the person hits the “bottom” of the pyramid. Boone also notes that the lowest level of the hierarchy – the meeting of physiological needs – is less involved with relationships with others (social), while the higher up the pyramid you go, the more the meeting of ones needs requires relationship. Early recovery, he therefore suggests, is by nature lonely, because often the meaningful relationships in ones life have been destroyed. The process of rebuilding ones life after it has been destroyed by addiction and after physiological stability and safety are achieved is largely about rebuilding and healing relationships, adding new ones, and likely abandoning some other ones. It is also necessarily developmental and stage-specific. And it requires time and patience!
Maslow’s pyramid has great relevance in looking at addiction, its consequences, and the course and stages of recovery. All of these things will influence the design of our model treatment components.
Applying the Pyramid to the Developmental Tasks of Treatment
We will put Maslow’s “Hierarchy of Needs” model to another use as well, and modify the lower four levels to describe the developmental needs of clients entering our program as follows:
Note that we haven’t changed the names Maslow gave each level, nor have we changed the content of the highest level, which he called “Self-Actualization.” We would be hard pressed to improve on that as a working definition of successful recovery!
One of the most pervasive trends in treatment the past decade has been the edict that no single treatment is appropriate for everyone. This principle, established by the National Institute on Drug Abuse (1999), recommends specifically that “Matching treatment settings, interventions, and services to an individual’s particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society.”
The model we are developing indicates that while individuals and their needs may differ, they do so at progressively higher developmental levels of recovery. We can generalize that the lower or more basic the needs, the less unique the problems presented, and the more universal our response can be. The higher up the levels of need in the hierarchy, the more comprehensive the assessment and the more diverse the resource and intervention options.
This developmental or sequential nature of the layers of the pyramid is an important principle when we envision, design, and particularly when we evaluate treatment services. A potentially troublesome but important reality is this: while meeting the needs at one level is required in order to meet the needs of the next, meeting those lower-level needs does not assure success at subsequent levels. Success at those higher levels is dependent upon far more variables than simply having met the needs of the previous level.
For example, we said earlier that it is hard to pursue employment if you are starving. One must have a level of physical nourishment to seek employment. But getting enough to eat in and of itself does not assure finding employment.
This seems perfectly obvious. But the thinking error of ascribing cause and effect upward across sequential levels of the pyramid is not uncommon among clients. Clients sometimes feel that because they have accomplished the tasks or milestones required at one level of recovery, the problems at higher levels ought to somehow automatically be resolved; finding a house, getting a good job, restoring family, getting a drivers’s license, and so on should proceed without special effort in that lower level tasks have been successfully accomplished. This is sometimes characterized as “magical” or “entitlement” thinking. Not only can one not skip steps, but the completion of each step does not assure that the next step will be easy.
Program administrators also sometimes share this error in thinking. This is because it is usually in the higher domains where the outcomes are written that have been used to justify funding. The point of the program after all, is that people become productive and self-sufficient members of society, that they become clean and sober, find jobs, stop committing crimes, and so forth. That is what the resources have been dedicated to achieve, so that is where there is a natural tendency to place the focus.
Researchers as well commonly share this error in thinking. Too often research studies will use outcomes at the third or fourth levels to evaluate the efficacy of interventions performed at the first or second level. If we design a research study to compare the efficacy of two methods of managing acute withdrawal, for example, it would be pointless to base the evaluation on whether or not people are still clean and sober 90 days after discharge. Whether or not people are still clean and sober 90 days after discharge will depend upon countless variables following the acute withdrawal or detox phase. The deceptively simple basis of the evaluation should be whether or not acute withdrawal symptoms were successfully managed.
Keeping the Focus
We wrote earlier about the seductive appeal on the program’s part of drifting into a focus on ancillary issues that the client brings rather than upon the primary focus of alcohol and other drug abstinence. There is a similar potential here which is the tendency to drift prematurely into the next domain. The program must have a strong sense of the integrity of each domain suggested by the levels of the pyramid, and address the treatment plan goals and activities on each of these levels before revising the plan to address subsequent levels. For example, people need time to stabilize in their withdrawal before detailed assessments of underlying mental health issues can be made; people need to feel a degree of safety before they can accept responsibility for their anger; establishing and pursuing educational goals should probably wait until people address emerging health issues, and so forth.
To illustrate the point further, consider what we have referred to as the Primary Treatment Domain (corresponding to the bottom layer of the needs pyramid). This domain might also be called the “Transition Phase” which includes addiction destabilization and detoxification – the transition from substance use to non-use. This phase would begin with the intervention that resulted in the client’s referral to treatment (a destabilization of active addiction) and proceed through acute detoxification.
Acute Detoxification as a treatment component is not usually regarded as having much intrinsic clinical integrity. “Detox” is viewed rather as a cumbersome but necessary “purgatory” to which people retreat until they are ready to begin the serious work of treatment and recovery. Identifying predictors of long term success among acute detox clients is nearly impossible: people who demonstrate high motivation at intake may fail, and those who appear highly resistant may succeed. Further, successful detox completion in itself has not been found to correlate with successful longer term recovery outcomes, and detox programs are therefore often characterized as “revolving doors” since many clients will attempt and succeed at detoxification numerous times before ultimately achieving recovery. For this reason, “free standing” detoxification without follow-up support is generally viewed as non-productive.
And yet, detoxification is the necessary entry point and precursor for alcohol and drug treatment, because the cessation of alcohol or illicit drug use is the foundation for any further therapeutic movement.
A base-line success indicator for this initial stage might be simply that “90% of clients will abstain from alcohol and illicit drugs.” This can be verified by a combination of daily urine testing, self reporting, and observation.
The focus of acute detox is to address alcohol or other drug withdrawal – sometimes called “abstinence syndrome.” Detoxification as a process can be defined in physical terms as a crisis of elimination (Smith and Kahn, 1988). Most detox focus is upon management of acute withdrawal symptoms. These symptoms, which vary depending upon the client’s drug of choice, include craving, anxiety, depression, tremors, excessive sweating, loss of appetite, sleep disturbance, nausea, headaches, and gastrointestinal problems. The successful management of these symptoms is the principal motivation clients have for ceasing their AOD use.
So a second primary base-line outcome success indicator may be stated: “95% of clients will experience a reduction of the presenting symptoms of acute withdrawal.” This may be verified by self-reporting or by medically diagnostic monitoring. Daily urinalysis will also be required to assure that the decrease in withdrawal symptoms is not the result of resuming alcohol or other drug use.
From a program perspective, there are two additional goals in this domain: (1) initiate the individual into the culture of recovery, and (2) facilitate motivation for the individual to make the effort.
Client Retention
Client retention is the central, necessary, and overarching goal of all substance abuse and chemical dependency treatment. Stated simply, if the treatment program can retain clients in treatment long enough for something significant to happen for them, then the client has a chance of achieving and maintaining rehabilitation; if the program cannot, the client’s chances of achieving and maintaining sobriety are slight.
“Secondary Domain Outcomes” will never be achieved if successful Transition and Stabilization do not occur. Conversely, if clients can be retained in treatment during the Transition and Stabilization phases, a significant percentage of them will naturally seek improved housing and employment, and will have reduced criminal justice and emergency health care utilization, either on their own or with minimal case management support and assistance from the program.
Significant resources, therefore, and service focus needs to be directed toward those outcomes and success indicators in the Primary Domains of transition and stabilization.
Client Choice
The higher up the hierarchy of needs, the greater the very important role of individual client choice. Some treatment programs do not believe that clients are capable of making choices about the treatment options that are best suited for them. Indeed it will be apparent that our clients will not have made the best choices on their own behalf as their disease has progressed. Part of the process of recovery if regaining the ability to make wise choices. The “Client-centered” program acknowledges that as basic needs are met, the more choices and options will be available and the greater degree of client involvement in making them. We again quote William White (2008):
There are times the recovery process may involve consciously not choosing — relying on resources and relationships outside the self, and times that the next recovery steps require an assertion of self. At a practical level, this means that the first hours of acute detoxification are not the best time to rely exclusively on client choice. And yet, long-term recovery is not possible without choice. If there is no rehabilitation of the power to choose and encouragement of choice, we are left with, not sustainable recovery, but superficial treatment compliance.
We will discuss all levels of the pyramid in greater detail in the Treatment Components section (below) and in our Treatment Manual.
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10 Core Elements of the Client-Centered / Recovery-Based Treatment Program©
May 9th, 2010 by restoringsanity.com
Introduction
The 10 Core elements described below are necessary and sufficient to provide AOD treatment that will bring about successful, sustainable, long term recovery.
All of these components are required to achieve that goal. Combined, they form a single configuration that satisfies all of the assumptions and presumptions we have thus far made.
It is important to note[1] that we do not suggest that the components and strategies proposed here only apply to one type of client, or to one type of drug, and that other components and presumptions are required for other types. Nor do we assert that there are different kinds of recovery that require a different set of treatment components. Effective recovery of any sort requires the preconditions and presumptions that we have described which operate through and with these 12 components.
Nor, finally, are we saying that these components are essential for “Client-Centered / Recovery-Based Treatment,” and that other components are essential for other kinds of treatment. We believe instead – based on experience, evidence, and common sense – that these components apply to any AOD disorders for which long-term, successful recovery is desired.
We welcome evaluation and testing of this model. But any research must test all of the components in concert. While each component may indeed have stand-alone value, or value in another context, it is the constellation of these components – each in the context of the others – whose efficacy should be tested. In this regard, the model is like an aircraft; you cannot remove a tail rudder and take it somewhere else to see if it works. It only works when attached, and if it is removed, the performance of the rest of the aircraft is significantly compromised.
The 10 components are:
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A Dynamic Community Interface
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Recovery-Based Case Management
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Housing and Shelter Options
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Acupuncture
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Urine Monitoring
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E-Information and Community
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Mental Health Services
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Medical Services
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Individual, Couples, Family, and Group Counseling and Education
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Vocational Services
Each is summarized below, and will be described in detail in our Client-Centered / Recovery-Based Treatment Program Manual© .
Core Element #1: A Dynamic Community Interface
The success of our treatment program will depend upon a dynamic and 2-way interface with the community it serves. Treatment is sometimes called “a revolving door.” Our optimum program will have swinging doors, with easy access in both directions.
To understand the importance of the community interface, let’s summarize two of the essential things that distinguish substance disorders from other illnesses (described above):
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Persons with AOD disorders generally fail to seek treatment on their own even when their condition becomes symptomatic.
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Long term recovery from AOD disorders uniquely depends in most cases upon ongoing, patient-initiated activities and involvement with non-medical, non-professional, indigenous community resources (e.g. peer-support groups).
The community Interface component of our treatment program will help respond to these two conditions. In terms of organization, it might properly be called the “Community Development Division” of our program or agency, because it needs to be dynamic rather than static. Staffing will include representatives of the local recovery community, volunteers, and peer-support interns, including treatment program alumni. Some agencies may want to consider delegating the operation of this division to a steering or advisory group directly representative of the local recovery community – including clients of the program – which in turn may be represented on the host program’s Board of Directors. In this manner a permanent and structural alliance would be formed between the treatment program or agency and the indigenous community recovery resources upon which it will depend for its clients’ success.
The community interface will also serve the agencies and institutions in the community (including families) where the negative consequences of AOD disorders are most felt.
At the core of this community interface will be an information “Drop-In Center” and 24 hour call line open to the public offering help for AOD problems in the form of education, brief therapy and intervention services. The Center should house a free physical and online library of AOD and recovery resources. Front line staff working in the Drop-In Center will be trained and certified in motivational interviewing, brief therapy, and intervention.
This Center will also provide alumni and client services including post-discharge monitoring, online support, social activities, community and recovery meeting space, and clean and sober community events.
It will also be a “marketing arm” of the program, promoting outreach services to venues such as public health clinics, jails, and shelters, participating in community health fares and similar events, and maintaining a “speakers’ bureau” of recovering people.
In urban areas, these Drop-In Centers might be positioned in a variety of strategic locations in the communities served as store-front outposts of the treatment program, where relapse prevention and acupuncture and related services may also be provided.
Additionally, when indigenous community supports are lacking at levels adequate to the needs of the program’s clients and alumni, this division will, through its peer networks, provide leadership in developing the needed resources. (An example would be when there is an absence of Rational Recovery groups in Spanish, it would provide volunteer leadership and meeting space and other needed resources to help develop these opportunities.)
Post-Discharge Monitoring*
In conventional AOD treatment design, there is a prescribed regimen of services, and when the client completes this regimen, he or she is finished with the program and “graduates.” Aftercare services are sometimes offered at no cost if the client chooses to return.
This approach is neither consistent with a chronic disease model, nor is it supportable by research. Stability with alcoholism (the point at which the risk of future relapse following recovery initiation drops below 15%) is not reached until 4 to 5 years of sustained remission. Other drugs may be longer. For mental illness, the point is reached at about three years.
Our optimum program will address these realities in three ways:
First, we will not propose a deadline or recommended time for discharge, eliminating the expectation that the client is going to graduate or complete the program in a finite period of time. This begs the question, how long will clients be actively engaged in treatment? The answer is that they should remain in treatment until long-term recovery can be self-managed by the client, family, and extended support network. That decision will be made by the client in consultation with the RCM, primary counselor, and family members and significant others.
Second, as part of our Community Interface, we will have a diversity of incentives for the client to remain engaged with the program following discharge. These include:
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Continued active involvement with the online Virtual Community
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Aftercare activities including acupuncture and Stress Management groups at the treatment site or at out-posted satellite locations.
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Program-sponsored Recovery events, trainings, and social activities
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Volunteer or paid or intern opportunities in the program.
Finally, we will provide assertive post-discharge monitoring for each client for a period of up to five years.
“Assertive” means that the monitoring will be the responsibility of the program and not the client. It may be delivered by the RCM, counselors, trained recovery coaches, or trained paid or volunteer peer recovery support specialists. It will emphasize contacts – both scheduled and unscheduled – in the client’s natural environment. It will also utilize email, mail and phone contacts. It will involve recovery coaching for family members and significant others, and will be individualized in the duration and intensity of check-ups and support based on each client’s degree of problem severity and the depth of his or her recovery capital, occurring with greater frequency the first 90 days after discharge and during pre-identified periods of vulnerability.
The goals of our component of community interface will therefore include:
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To expand awareness of AOD problems and recovery opportunities in the community.
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To serve as a repository of information and resources for the community at large on issues relating to AOD problems and their resolution.
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To develop and provide strategies for increasing access and engagement and removing barriers for all in the community who would benefit from AOD treatment, and to facilitate treatment entry through intervention, motivational interviewing, and other direct services.
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To develop and provide strategies for increasing the retention of people in treatment through engagement with indigenous community resources, and to provide leadership in the development of those resources as necessary.
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To monitor clients and their families for long-term success through engagement with natural recovery supports.
CC/RB Core Element #2: Recovery-Based Case Management
A foundation service of our program will be recovery-based case management. Clients will be assigned a Recovery Case Manager (RCM) on their first visit, and the RCM will continue to support them during their treatment stay through post-discharge monitoring. The RCN’s primary responsibilities include (1) assuring that the client becomes engaged with the natural community recovery supports most appropriate for them; (2) determining through ongoing assessment all of the barriers to recovery – familial, social, relational, physical, mental, legal – that threaten such engagement, and (3) assuring that clients find and access all community resources necessary to overcome these barriers and meet these ancillary needs.
They will meet with and monitor the client throughout treatment, involving family members and significant others as appropriate, and providing transportation as necessary. They be trained and/or certified in administering GAIN assessment; brief therapy; motivational interviewing; intervention, and the Community Reinforcement and Seeking Safety approaches to treatment of substance abuse and trauma. Their loyalties, however, are not to any one of these interventions or approaches, but to the client.
They meet with their clients with gradually declining frequency as the client stabilizes. Individual or family sessions may be at the treatment site or at the client’s home or in the community or online. The RCM also holds regular on-site group sessions for clients on their case load.
They provide leadership in casing and – along with the client and his primary counselor – in developing and monitoring the treatment plan and the discharge plan, assuring that natural community supports are capable of sustaining long term recovery with no further need for formal treatment, and participating – with other recovery support staff – in ongoing post-discharge monitoring.
CC/RB Core Element #3: Housing and Shelter Options
Adjunctive clean and sober housing:
As we have noted earlier, the primary advantage of outpatient treatment is its ability to tolerate use episodes without having them result in treatment discharge or drop-out.
Yet we acknowledge the need for clean and sober housing for many people during and – in some cases – for months following treatment.
These clean and sober housing opportunities need to be available and accessible to all program clients. If they do not already exist at necessary capacity, the treatment program either needs to facilitate their development or open and manage them itself.
The most important thing about these housing opportunities is that they operate independently of the treatment program to the degree that a client being discharged from treatment for any reason does not automatically result in eviction from their housing.
Nor, in the reverse, should eviction from the client’s housing have and effect on their treatment status.
There are many models upon which this housing might be managed. Recommended guidelines include the following:
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There should be a mechanism of cooperative and meaningful resident participation in management of the facility.
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The facilities should be gender specific, and may also specialize by age, type of drug, sexual orientation, ability to accommodate children, language or ethnicity, co-occurring disorders, preferred support group (e.g. AA, RR, MM) etc. The primary requirement for admission should be a sincere desire to recover.
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People should not be denied admission because of lack of money. However, the house should be financially self-supporting to every extent possible. Everyone who is able should be expected to pay their own way. Room and board rates should be on a par with the bottom of the local rental market.
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These facilities are not a permanent residence for either residents or staff.
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Any resident in possession of or under the influence of alcohol or illicit drugs should be asked to leave. Previous recovery attempts should never a barrier to readmission, though detoxification or a brief period of abstinence may be required.
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Residents without jobs who are able to work must seek employment as soon as they are able. All residents should help maintain and operate the house as it were their own home.
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There should be no fixed term of residence – the individual himself determines when it is time for him to leave.
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All residents are strongly encouraged to fully participate in community recovery support programs, and it is encouraged that meetings are held on-site.
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Except for specialty homes for persons with disabilities or other co-occurring disorders, staff should be non-professional. The positions of managers, assistant managers, cooks, and even the director positions should be filled from among the resident population, and front-line staff should be required to live on-site. The positions should be temporary, providing transitional vocational opportunities to people new to recovery. Staff may provide information about community resources, but they are not counselors. Staff salaries are enhanced by free room and board. To every extent possible, specialty house maintenance such as painting, electrical, plumbing, and refurbishing is also performed by residents in lieu of rent.
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Though peer support meetings may be held on site, there are no therapy or formal treatment services offered.
The ability to be relapse tolerant on the part of the program will not be shared by the housing facility, since maintaining a clean and sober environment is essential to the success of these programs. This is why our program needs either to operate or enjoys a close referral relationship with a residential, short-stay detox facility.
Residential detox:
Our residential detox will be available for clients who have temporarily lost their housing due to relapse, or who have not been able to successfully detox on an outpatient basis. It will be sparse, a “social model,” providing food and shelter. It should be gender-specific or at least gender-sensitive and in reasonable proximity to the treatment program. It need not be licensed as all clinically-supervised services will occur at the Treatment Program, which detox clients attend daily.
The Detox may also serve as a “sobering station” drop-off or similar alternative to jail for public inebriates and hence a further entry point for treatment
Core Element #4: Acupuncture
Auricular (ear) acupuncture is a core element of our optimum program. Acupuncture (1) helps people feel better without using substances, (2) operates in the present moment and (3) provides a ritual experience for program/recovery initiation.
This acupuncture protocol also:
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Reduces symptoms of both acute and post acute drug withdrawal;
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Prevents relapse and use episodes by reducing the stress that leads to craving;
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Reduces denial and treatment resistance;
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Shifts the client’s attention from the external “fix” to inner healing resources;
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Makes the client more psychologically available for group counseling and for other verbal interventions;
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Increases opportunities for and provides an introduction to peer recovery support, and
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Creates a welcoming, client-centered, recovery culture within the program.
The acupuncture clinic, properly organized, additionally provides a premier opportunity for gathering basic information for monitoring client progress and assessing client needs. Clients will begin their visit each time they come to the program with an acupuncture treatment. The clinic is staffed either with licensed acupuncturists or – where state laws allow – by “Acudetox Specialists” who work under the supervision of licensed acupuncturists. The clinic is also staffed by clinic monitors who are there to assist clients, answer questions, and serve detox tea – a special herbal mix designed for this setting.
The protocol for the acupuncture clinic is that clients sign in, get their own package of sterile needles, prep their own ears with an alcohol solution, and fill out an Acupuncture Clinic Treatment Card while they are waiting for their treatment.
The acupuncture treatment takes about 45 minutes, and is offered a minimum of 1.5 hours early in the morning prior to the first group session (e.g. 7:00-8:30 AM), and for the same period in the early evening before the first scheduled evening group (e.g. 4:30-6:00 PM). Some clinics with a large client census may offer the service for extended hours.
Below is a sample Acupuncture Clinic Treatment Card to illustrate the kind of data we want to monitor. These cards are collected by the clinic monitor and delivered to an administrative staff member who enters or scans the information in the Client Data Base. The data is used daily by the client’s Primary Counselor and RCM, and is used in weekly casings with all clinic staff.
Core Element #5: Urine Monitoring
The program has daily urine monitoring as a normal part of its required protocols. Multiple client urines are tested at once, and the data is downloaded to the client’s attendance file. Toxicity patterns over the period of the client’s treatment attendance can be generated instantly.
The notion of urine testing in a therapeutic setting may seem ill-advised, since urine testing is traditionally punitive, giving the treatment program the role of critic rather than supporter of the client’s recovery process. In practice, however, quite the opposite turns out to be the case. The goal is not punitive disclosure but education and therapeutic feedback. Unlike urine testing in a law enforcement setting, clients assume the responsibility for self-monitoring the urinalysis process, gathering the sample unobserved. Once the treatment rhythm has been established, and once the client has learned that a positive test will not result in program expulsion, attempts to deliver “false negatives” will be uncommon.
Providing daily urine testing at an AOD treatment program should be seen as similar to providing scales at a weight loss clinic, or a glucose monitoring device to diabetics. The “instant” feedback that can be provided through the use of technology will be reinforcing for the client and will automatically serve to ameliorate denial of the consequences of substance use. The technology we recommend does not deliver a positive or negative result but rather the degree of toxicity, and the report shows multiple days, so that the client can see trends, such as the exact length of time it takes drugs to leave his or her system, and any patterns of use (e.g. weekends).
On each treatment visit, the client will meet individually with their RCM or program counselor, and the session will include information from that day’s urine test. The staff member will never have to open the session with the problematic, “How are you doing” because “how the client is doing” is already objectively established. The content of the answer to the question, “how are you doing?” is not being elicited by the counselor or case manager. Nor does the answer depend upon the client’s best recollection of when he or she last used, but rather has been provided by the client’s own body.
Once educated about this procedure, most criminal justice referring agencies will be satisfied with this level of monitoring. Forensic testing may be referred out as required.
Core Element #6: E-Information and Community
We propose a three-tiered information system in our treatment program.
Tier 1:
The first tier will our confidential client data base, accessed only by staff, with client attendance and progress information used for clinical monitoring. Besides the acupuncture clinic card data and urine test results – both of which will be gleaned with each client visit to the program – there will be status reports from a variety of individual and group episodes and activities. All of this data needs to be immediately charted so that the RCMs and counselors can access the latest information that has been charted about their clients. Portable electronic devices should be available for this, so that data can be accessed anywhere.
Tier 2:
The electronic environment will include areas that clients may also access. The program will have a library/lounge area with PC stations, and clients will have a password that allows them to use their own electronic devices for access to the treatment program’s Virtual Community (VC).
The VC will have a general area where people can post and read the posts from others, and where people can post questions about recovery, drugs, the program, and community resources. Program staff and volunteers will monitor the environment continually to assure that it is one that is safe and therapeutic. Clients can access forums and discussion groups on specific topics, ranging from housing and employment to HIV information and the interactions of different classes of drugs.
When the client is online, the information she posts and the questions she asks will also be housed in Tier 1 in the client’s confidential record, so that the RCM and Counselors may access it along with the other progress and status information. staff and volunteers will also maintain a presence in the CV to monitor discussions and to post answers to the questions that are being asked.
Tier 3:
The least secure area of the information system will contain resources on housing, jobs, education, and recovery resources and activities and special events in the community. It will also contain basic information about AOD issues and about the treatment program, such as training schedules. This area will be accessible to the general public.
Core Element #7: Integrated Mental Health Services
When mental illness co-occurs with a substance disorder, treatment for both disorders needs to be integrated.
One of the clinical challenges in organizing these services is that acute withdrawal symptoms from many classes of substances mimic the symptoms of some mental illnesses. Further, for some chronic substance users, the substance use masks deeper mental illness. In both of these cases, accurate diagnosis and the sorting out of problems is difficult in the beginning. An initial brief medical screening upon entry to the program may reveal that the client has a history of mental illness. But in general we will need to wait until the client has stabilized and withdrawn from alcohol and illicit drugs to make accurate diagnoses.
Acupuncture allows time for this to occur. The same treatment protocols are used for everyone entering the program, and all withdrawal symptoms will be closely monitored through self-reporting on our Acupuncture Treatment Card (above). People with co-occurring AOD disorders and mental illness can be accurately assessed once the acute symptoms of chronic drug use have dissipated. Treatment for their mental illness may then be incorporated and integrated in their treatment plan.
The program goals for people with co-existing substance abuse and mental health issues are to:
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Detox from alcohol and illicit and other abused drugs;
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Stabilize the use of prescription drugs for the mental illness through assessment and continuing daily acupuncture;
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Treat the co-occurring disorders with acupuncture, individual and group counseling, case management, and medications.
Core Element #8: Integrated Medical Services
Licensed medical staff will be available on a regular schedule and will include both primary medical and nursing services. Physicians and/or physician’s assistants must be addiction certified with a willingness to practice general medicine. Nurses will require certification in addiction.
A very brief physical exam along with testing for HIV/AIDS, TB, and Hepatitis C should be performed on intake, with results reported to the client by the program’s physician at the program site.
Many conventional AOD treatment programs employ medical services at the beginning, usually to address acute withdrawal. Our medical services will be utilized later, as medical conditions either long ignored or resulting from drug use become apparent. Our program’s medical staff should perform physical exams and tests as people begin to stabilize.
Program monitoring – particularly the data that is collected from urine testing and in the acupuncture program – will reveal these underlying or “masked” pathologies as the client begins to detox. Some symptoms (e.g. nausea, headache, anxiety, depression, insomnia) are common in acute withdrawal. It is also normal to see these symptoms begin to lessen in the first days of abstinence. If the person has been clean and sober for several days and certain symptoms are persisting, a medical or psychiatric assessment and further treatment may be indicated.
It is preferable if people can safely and effectively withdraw without using other drugs. Note that it is our program philosophy to begin with the least invasive interventions. It is rare that clients are not able to successfully and safely withdraw with acupuncture only, but our daily monitoring and urine testing will quickly indicate when people need medical assistance for detox, and this will be available through our medical services.
Core Element #9: Individual, Couples, Family, and
Group Counseling and Education
Individual, Couples, and Family Counseling
Clients are assigned a primary counselor upon program entry. The counselor will meet individually with their clients for 10-15 minutes on each treatment visit and will be the client’s primary VC resource.
The primary counselor, based upon input from the client and the client’s case manager, will provide further individual counseling sessions on issues that present barriers to the client’s recovery, and counseling sessions involving the significant others in the client’s life, including spouse, friends, and family members.
There will also be weekly family and couples support groups.
Group Activities
A front-line core service in our treatment curriculum will be Stress Management groups.** Several will be available each day at times convenient to all clients. The design allows that it may accommodate from two clients to as many as fifty. The time frame is optimally 1 ½ hour for 15 or more in attendance. The leader is a facilitator, and needs special training only in the procedure the group will follow.
The Stress Management group format has five steps.
Step 1: Education. The leader makes a brief presentation educating people about the relapse model being used (the stress-craving model that we have described earlier) and what will be happening in the group.
Step 2: Check-In. The facilitator asks members of the group to “check in” by stating their name and then reporting their present level of craving on a scale of one to ten.
Step 3: A Volunteer. Someone whose level of craving is five or higher is asked to volunteer. They share with the rest of the group what stressors are going on in their lives that they think might be contributing to their craving.
Step 4: Feedback. Others in the group are asked to give feedback to the person who has volunteered. This can be in the form of questions, suggestions, or similar experiences, and the volunteer is free to respond or just listen. The ground rule for the group is that no negative judgments are shared.
Step 5: Summary. The facilitator summarizes the information that was shared, and the volunteer reports on whether he or she felt it was helpful and what action steps they plan to take.
This process is intended to be therapeutic for everyone, but it is also a tool for monitoring. The facilitator will enter confidential notes in the program’s Tier 1 electronic data base about important events that occurred during the group, including the names of persons who reported cravings higher than six.
Since these are non-clinical, peer-support groups, they may be operated by the treatment program at multiple locations. Some programs may have Stress Management groups open to the public (particularly alumni) as a function of their Drop-In Center, as the groups are not substance specific and have value for people struggling with any addictive behavior.
Other formal group activities include cognitive skills development in anger management, conflict management and resolution, life skills, alcohol and other drug and addiction education, nutrition, relationship issues, motivational issues, relapse triggers, and thinking errors. These will be provided in gender-specific and – as required – language-specific groups.
Material covered in groups will be sequential. New people can enter and complete specific phases with varying intensity of attendance as required by their treatment plan. For each topic there will be a manual that includes a leader’s guide and handouts and supplemental audiovisual materials and films.
Less formal gender-specific support groups will also be provided on site, including Recovery Resource groups for newcomers.
Tobacco cessation groups may also be provided.
All program counselors and group leaders will be trained in and employ the essential elements of Motivational Interviewing and the two treatment models: Seeking Safety and the Community-Reinforcement Approach.
Core Element #10: Vocational Services
Certain factors predict poor outcomes in treatment. We have already addressed a lack of safe and supportive housing (living environment) and untreated mental illness. Another is the inability to meet short and long term vocational goals.
Our treatment program will have staff dedicated to finding and developing short term job opportunities. Some of these will be at the treatment program itself and adjunctive support services such as resident housing staff positions, acupuncture clinic monitors, online VC monitors and technical support, and urine monitoring support staff. These are all positions that can be filled by newer clients (with six months or more of sobriety.) Our vocational services will also cultivate day job opportunities in gardening, house cleaning, construction, etc., and our VC will have an online jobs bulletin board linked to Craig’s List. Staff will also utilize community resources in computer training, literacy, resume development, and job readiness workshops.
Vocational case management will work with people doing vocational assessment and goal setting to support people in achieving longer term educational and vocational goals.
* For this section, we are most and additionally indebted to William White (2008).
** (For this section, thanks again to Alex Staclup, MD)
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Goals
May 8th, 2010 by Deecdoneedefs
Client-Centered / Recovery-Based Treatment for
Alcohol and Other Drug Disorders
Sample Goals
A. Goals for the Program
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To identify and develop a wide variety of community venues for identifying people in need of AOD services and providing them with the support and assisting them in developing the motivation necessary for them to become attracted to and engaged in treatment and recovery activities.
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To provide professional services that are the least invasive and the least intensive possible based upon the needs of each client and that are organized around the presumption that clients desire long-term recovery.
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To create a culture that is welcoming of all persons with alcohol and other drug problems.
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To assure safe and supportive housing as needed for all clients.
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To retain people in treatment in spite of use episodes or relapse.
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To achieve a structure and organization that meets the needs of clients with different levels of support need and with a variety of work schedules.
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To fully and rigorously assist clients in finding the natural recovery supports that are right for them based upon their life style, gender, culture, values, etc.
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To fully and rigorously assist clients in removing the barriers that prevent them from long term engagement with these natural supports.
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To utilize and develop as necessary social, recreational, familial, and vocational resources to assist the client in the recovery process in order to make a sober lifestyle more rewarding than the use of substances.
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To facilitate the development of relevant recovery resources when they are needed in the community.
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To develop and sustain (a) methods of daily monitoring of the conditions that predict relapse and (b) strategies for their immediate resolution.
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To assure that clients remain engaged in activities that support sustained recovery following treatment discharge for a period up to five years.
B. Goals for the Client
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To become abstinent from alcohol and other non-prescription mood-altering drugs.
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To participate with their primary counselor and case manager in the development and subsequent revision of their individualized treatment plan.
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To participate in all program activities indicated by their treatment plan.
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To cooperate with the Recovery Case manager in accessing community resources that will help them meet their goal of abstinence.
Note: Treatment Plan Goals and Objectives for the client may be simple in the beginning (e.g. come back tomorrow.)
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Costs
May 7th, 2010 by Deecdoneedefs
We have been describing Client-Centered / Recovery-Based Treatment for Alcohol and Other Drug Disorders – our Best-Practice Model.
We now consider what treatment would cost using this model
Most discussions of the cost of substance abuse treatment begin with a caveat about the costs to society of not treating it, and of the high dividend returns to taxpayers and the workplace of investing in comprehensive treatment.
How strange it would seem if similar rationale were given in preface to discussions of the cost of treating cataracts, lupus, an abscessed tooth, or high blood pressure!
As we mentioned in our preface, our treatment program has not been designed based on cost considerations; instead, our design is based upon what is necessary and sufficient for successful long-term recovery.
We didn’t cut any corners. Nor were we lavish in estimating program costs.
In determining what it does cost we used the following methodology:
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We tracked three hypothetical clients over five years, with varying levels of need and relapse frequencies, and averaged the number of “treatment visits.” A typical “visit” might include an acupuncture treatment and a urine test, a fifteen-minute check-in with the primary counselor, a meeting with the Case manager, time to log into the virtual community, and two or three group sessions. We included pre-treatment visits (family intervention, motivational interviewing, etc.) and post-discharge monitoring, including three hypothetical significant program reengagements in the four years post-discharge. We also included medical and psychiatric services and group and individual counseling and Recovery Coaching for significant others and family members, both on-site and in the community;
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We developed comprehensive budgets for programs of three sizes: one with an annual unduplicated client count of 60, one with 120, and one with 300, and averaged the costs (costs per client are generally lower in larger programs due to economies of scale). We did not include start-up costs.
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We presumed that 55% of our clients would require clean and sober housing for an average of 12 months, and that 80% of the house rental costs would be paid by the client, with the balance paid by the treatment program (this was the only budget item partially subsidized by the client). Also included in sober housing were food costs, child care, and house management and maintenance costs.
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We presumed that 40% of unduplicated clients would require residential detox for at least 10 days at some time during their stay.
Our program costs also cover all components described in our program design, including:
-
A fully staffed Drop-In Center with information, outreach and intervention services;
-
Recovery Case Manager and Primary Counselor case loads of 1:12;
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On-site psychiatric and mental health services with estimated co-occurring chronic and severe mental illness among clients at the rate of 50%;
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Lab fees and medical supplies (in addition to daily urine testing and acupuncture) at an average cost of $700 per client (we did not include prescription drug costs).
Treatment costs will vary considerably depending on regional cost-of-living factors which will significantly influence facility rents and salaries. For purposes of comparison, our sample budgets computed rent for a four-bedroom house at a national average of $2000 monthly, a nurse’s salary at $22.00 per hour, a physician’s salary at $55 per hour, and a certified but non-licensed counselor at $14.00 per hour.
We budgeted fringe benefits at 20% of salary. Below is the level of staffing (FTE = Full-Time Equivalent) that we calculated for the smallest of the three hypothetical programs, which would have 60 unduplicated clients per year.
Program Director 1 FTE
Program Assistant 1 FTE
Administrative Support 1 FTE
Drop-In Center Director 1 FTE
Development Consultant .25 FTE
Volunteer Coordinator 1 FTE
Technical Support 1.4 FTE
Recovery Case Managers 4 FTE
Counselors 5 FTE
Acupuncturist .53 FTE
Clinic Monitor .4 FTE
Physician .7 FTE
Nurse .5 FTE
Urine Technician .4 FTE
Psychiatrist .53 FTE
Vocational Case Manager .35 FTE
Recovery Coaches/Peer Support 5 FTE
Accountant 1 FTE
Sober Living Managers and Assistants 5 FTE
Sober Living Cook and Assistants 2.5 FTE
Residential Detox Manager and Assistants 3 FTE
Child Care 3 FTE
This small-sized program also has an operating budget (in addition to salaries and benefits) of $834,000 plus an additional 6% additional administrative overhead.
The Bottom Line
Following are the treatment costs for our program averaged across all 3 program sizes:
Cost Per client total (for 5 years): $30,500
Cost per Client per Month (12-month basis): $2,550
Cost per Client per Week (12-month basis): $588
Cost per Client per Visit: $185
How does this compare with other kinds of treatment programs?
A quick search of treatment costs at this writing showed a referral service in Florida advertising $12,900 for 30 days (compared with our $2,550), and a treatment program in Southern California advertising a special of $23,800 for 5 months (ours would be $12,750 for the same period), which included 2 months of sober living (ours would include sober living for all five months), and a standard rate of $11,800 for 30 days (compared, again, with our $2,550). The National Substance Abuse Treatment Services Survey found an average monthly price of approximately $7,000 for drug treatment facilities. According to NIDA (1998), “For most patients, the threshold of significant improvement is reached at about 3 months in treatment.” A typical minimum treatment stay is therefore 90 days, or $21,000 (compared with $7,650 for a 90-day stay at our program).
Note that typical treatment programs – regardless of the average stay – discharge people with little follow-up. Our program is designed (and our budget calculated) to retain people in active treatment for an average of 12 months, and then to provide proactive monitoring for an additional four years with re-admissions to treatment as necessary calculated in our cost projections.
The reason our costs are so favorable compared with others is that it is outpatient, with sober housing as an adjunct, and the use of acupuncture dramatically reduces medical detoxification costs.
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May 4th, 2010 by restoringsanity.com
On Looking into William R. Miller’s
“Disseminating Evidence-Based Practices in
Substance Abuse Treatment”
© 2010 by Alex Brumbaugh
What is my problem with “evidence based practice” (EBP) in the treatment of substance use disorders and addiction?
I need to take a look at that.
I have so much first-hand knowledge of the immeasurable pain and suffering involved in chronic substance use disorders, both for the patient (alcoholic or addict) themselves and for those who love them – that one would think I would be at the very front and center of the crowd demanding that treatment programs only use things that have been “proven” to work – things that meet the gold standard of “scientific evidence.”
And yet, I have a problem. Something must be wrong with me.
That reminds me of a joke. People new to the alcohol and drug treatment biz may not have heard this one. It is something they used to say in Minnesota. “In Minnesota, they say that if you aren’t in treatment, or thinking about getting into treatment, there’s something wrong with you.”
My problem could be that I have a resentment against medicine, psychology, scientific research, and the criminal justice system for coming late to the party and now wanting to take it completely over.
That is a bit disrespectful on their part, after all, and not just a little arrogant.
Or is that just me?
As a faithful and long-time subscriber to Join Together Online, and hence one who bathes regularly in the Latest Research on substance abuse, and as someone who has now read (most of) the venerable William R. Miller’s exhaustive review (2006) in the Journal of Substance Abuse Treatment of EBPs and the efforts that have been made to get them safely ensconced in all the substance abuse treatment programs of the land, I have a sentiment that I can no longer keep bottled up:
What we really need in the substance abuse treatment field is a little less science and a little more common sense.
A caveat: William Miller is brilliant. Brilliant and prolific. It would be an honor and great fun I am sure to be in one of his classes in alcoholism at UNM.
Let me also say that I am a devotee of a couple of the most innovative and powerful EBPs around – namely Lisa Najavits’s brilliant Seeking Safety for substance abuse and trauma, and Robert Meyers’ and Daniel Squires’ rich and sorely needed Adolescent Community Reinforcement Curriculum.
Or is it arrogant on my part to express value judgments like this? Isn’t it just about the … evidence? Who, after all, am I?
But – insofar as I am allowed a personal opinion – let me also say that William Miller’s EBPs on brief intervention and motivational interviewing are stellar breakthroughs.
But back to his article.
It is exhaustively comprehensive – 36 pages long, with 149 references.
A side note: Fourteen of those references are to publications authored by Miller himself. That’s a rush with which I am not completely unfamiliar, having myself once published an article in the Journal of Substance Abuse Treatment and having twice had the opportunity to cite it – once in a book I wrote in 1993 and again in the only other article I have ever published, in a journal called Addiction and Recovery that is now defunct.
But this isn’t about me.
Miller talks in his article about the “natural diffusion” of EBPs from the research community to the treatment community. He suggests however that something in that process is not flowing quite as “naturally” as it ought. Programs cling to the old ways, the ineffective, non-EBP ways.
He also talks about levels or standards of efficacy. The gold standard of EBPs are clinical trials, of course, good old fashioned double-blind replicable research studies. EBPs are also established by the consensus of professional people working in the field. This is what comprises the “Treatment Improvement Protocols” (TIPS) of the Center for Substance Abuse Treatment. (William Miller is so successful that he has a TIP of his own – TIP #35. Nice!)
On lower levels of efficacy, according to Dr. Miller, there are what he calls “unevaluated” treatment methods, for which there has been little or no research and whose efficacy, therefore, is not known.
That means that there are things that people are doing to other people in substance abuse treatment programs about whose value nobody knows anything because the Professional Scientific Researchers haven’t studied them yet.
Next come “disconfirmed” treatment approaches. Some research has been done on these approaches, but they have been – in Miller’s words – “found wanting.”
And finally we have treatment methods that have a long history of negative findings in clinical trials yet continue in widespread use.
“For example,” Miller writes, “many substance abuse programs continue to use educational lectures and films as a standard component of treatment, unaware of dozens of clinical trials showing no impact of such didactic approaches.”
To provide evidence for this breathtaking assertion (coming as it does from a person whose primary profession is teaching) Miller cites two sources. The first one is a 1995 paper by D. A. Davis and others called “Changing Physician Performance: A Systematic Review of the Effect of Continuing Education Strategies.” I am putting this article on my list of things to read to see if it successfully debunks the impact of educational lectures and films in substance abuse treatment. (Based on the title, such a finding would be so tangential to Davis’s main topic that I will be curious to see how he works it in.)
The second source Miller cites for his broad assertion is a chapter he himself wrote for the 2003 Handbook of Alcoholism Treatment Approaches. This book has gone on my Amazon wish list. The cheapest used copy is $63.18. It lists new at $95.00. It’s not at the top of my wish list, so I will need to wait awhile to take a look at the “dozens of clinical trials” from which he is drawing his conclusions.
In the meantime, here is something: I got sober in 1983 at a men’s alcohol rehab in Southern California. One night during the first dark week of my stay there, with my eyes still blurry and my body still shaking, the house manager rolled in a rickety 16-millimeter projector and showed an educational video by Father Joseph Martin called “Chalk Talk on Alcoholism.”
I recall to this day that experience, sitting in that darkened room watching the grainy images of a Catholic priest standing at an old-fashioned free-standing blackboard. I don’t recall what he said. I remember that at one point he turned the blackboard around. He had written stuff on the other side. Whatever it was, I knew for the first time that I wasn’t alone in my personal struggle with alcohol.
I was forever changed. I never drank again.
Some impact!
In Miller’s realm, educational films – more than being of questionable efficacy in the treatment of alcoholism – actually get a negative score. In the chapter he wrote for that 2003 book, he made a table. I found a copy of it on the internet for free. The table gives education (tapes, lectures and films) the value of minus 443 (emphasis mine). He has a ranked list of 48 interventions, and education (tapes, lectures, and films) ranks last – #48.
Miller provides – as only a scholarly researcher could – the following explanations of the numbers and rankings used in the chart he made. I quote directly:
Cumulative Evidence Score (CES). The CES is figured in this way. For each study, the Methodological Quality Score is multiplied by the Outcome Logic Score (not shown). Then (we) added up all these scores for a particular modality. So the CES is a function of the number of studies, the scientific rigor of each study, and the outcomes for a treatment within each study.
Mean Methodological Quotient Score. This is the average score of the scientific rigor of each study in a particular modality. Scores can range from 0 to 17.
Mean Severity of Treatment Population. This reflects the average of how severely dependent the population studied was. Scores range from 1 (less severe alcohol related problems and dependence) to 4 (severe alcohol dependence).
% Excellent. This is the percent of studies in each treatment category that had high Methodological Quotient Scores (>13 on scale of 1-17).
I am tempted to rest my case about less science and more common sense.
But instead, let’s press on.
Let’s imagine that the EBP-related tidbit in question – that educational films are worse than worthless in treatment as to their impact – were “successfully and naturally diffused.” For what outcomes would Miller then hope as a consequence among treatment program managers and administrators?
Would it be that they burn all the movies in the house – including those of Father Martin?
If not, why not?
Could it be that Miller would assert that the immensely positive impact that watching Father Martin’s “Chalk talk” had on me is zeroed out by a commensurate negative impact on the man sitting next to me on that dreary night in Southern California? It may have so shamed that man that he went out and got drunk, and subsequently died of an overdose. Who knows? People were going out and dying of overdoses all the time at that rehab. If the forensic scientists had been rigorously on the scene, it would have made – if true – quite a headline: “Alcoholic dies of educational overdose – relapses after watching Father Martin film.”
How would William Miller respond if he and I were talking and I told him that watching that Father Martin film saved my life? Well, I don’t believe it literally saved my life. To state the case with less drama and more scientific accuracy – that I am sure Miller would appreciate – I would say that what it did was contribute to saving my life because it helped keep me in that rehab long enough for significant changes to happen.
There’s a thought. What if movies improve program retention? Can we prove that? Has anyone looked at that?
Here is something else that I am curious about. Would Dr. Miller – based on the studies he has reviewed – have an interest in the film’s content? Does it make a difference what the film is about or who is in it? Would he equate, for example, the intense didactic lectures of John Bradshaw, the fatherly ones of Ernie Larsen, or the electrifying ones of Michael Johnson with dramatic emotional submersions such as Lost Weekend, Days of Wine and Roses, or Basketball Diaries?
In the presumably numerous education-debunking studies that Miller carries in his briefcase (to which one is not privy without buying the $95 book), are there distinctions drawn if the material in the film happens itself to be evidence-based? I am thinking for example of the brilliant Commitment to Change video series by Dr. Stanton Samenow, the preeminent criminal justice researcher who has more than any other individual brought cognitive therapy to substance abuse, mental health, and reentry programs in federal and state correctional institutions.
Cognitive therapy gets a stellar 21 score on Millers efficacy table, ranking #13 right behind Case management. Is cognitive therapy completely negated in value if it is presented in video format? If yes, the assumption is that the counselor in the program who is doing the cognitive therapy is in every case more efficacious than Dr. Stanton Samenow, even if she is a terrible therapist. It doesn’t matter who she is or what mood she is in, or how poorly trained or culturally incompetent she is, because she is in the flesh, and Dr. Samenow is only digital. She beats him every time.
BTW, if movies are at the bottom of Miller’s efficacy table, is anyone interested in what is at the top?
Number 1 is “Brief Interventions” and number 2 is “Motivational Enhancement.”
On that subject, I know what someone is going to say. They are going to say, “Oh, I’ll bet you are just saying all this because you are probably in the substance abuse movie field and just want to bolster sales.”
The answer to that is, as a matter of fact – spoiler alert! – I am! I am an education and treatment consultant for the company that distributed that very Father Martin video that I first saw so many years ago.
Why am I doing that?
Because I know from personal experience how important those different voices of recovery can be for people who are struggling.
To which Dr. Miller would say … what? That that weighs for … what? That my professional life is a … negative what?
And what would I say to Dr. Miller in that the interventions he largely developed personally and profits from every day are at the top of his list?
I would say, “Bravo!”
On that subject, if Dr. Miller so doubts the efficacy of educational videos, how come he has more than a dozen of them on motivational interviewing for sale on his website? He has some in three languages. They cost around $150 each.
* * *
Let’s look closely at education itself – whose impact Miller discredits – as a substance abuse treatment tool.
Can one imagine an educational lecture on cocaine being delivered to a room full of cocaine addicts as being really, really, really bad for them?
I can. As an alcoholic and addict, I will be the first to say how much I hate patronizing, harping, didactic, arrogant “health lecturers” telling me about my body. I hate them even when they are well organized, even when they have Power Point and nice charts and graphs and when I am sitting in a nice theatre-style cushy lodge chair with comfortable arms. I can see them making me want to go out and get shit-faced, blitzed!
Does that mean on the other hand that information about the process of neuroadaptation of dopamine receptors in the brains of cocaine users and its impact on craving cycles is of no value to someone struggling with recovery from cocaine? – That knowledge of that would somehow not have some positive impact on the success of his or her recovery? Or that education about the relationship between stress and craving would consistently have zero impact on a recovering heroin addict?
That’s not my (for what it’s worth) experience.
The point is that the essential variable in the impact of education is the context in which it is presented. If a parent gives their child educational information about drugs, is that an efficacious intervention? It depends upon the context. For example, is the information delivered in a loving context or an angry or confrontational one? Is it presented in a timely manner, or while the kid is on the way out the door on prom night? One could possibly list a hundred contextual variables that would influence whether or not the presentation of educational information had an impact that was (a) beneficial or (b) harmful or (c) neutral.
How many variables can you think of?
The important question for purposes of this discussion is, were all these variables accounted for in the clinical trials on the educational lectures that produced Miller’s thesis that such components in treatment programs deserve a minus 443?
The follow-up questions would be, if not, what is Miller saying? And why is he saying it? And why would someone of such reputation and brilliance bring his full academic and professional weight to a categorical debunking of the role of education in a forum as prestigious as the Journal of Substance Abuse Treatment?
Okay, maybe he is just saying, “If you are going to give the alcoholic client a bunch of facts about alcohol and the liver and if that’s all you are going to do, don’t think you have done a good job in treating him.”
I couldn’t agree more. I am a former high school American History teacher, and hence not one to overvalue education, especially if it is spotty. We used to have a saying: “If you are going to cover the Civil War in two days, forget it because the students will too.”
Context is everything – in teaching, in child-raising, in substance abuse treatment.
Isn’t that just common sense?
* * *
Miller goes on in the article in question: “Similarly, controlled trials have shown little or no beneficial impact on substance use outcomes from interventions such as acupuncture, confrontational approaches, insight-oriented group or individual psychotherapy, or mandated (emphasis his) Alcoholics Anonymous attendance.”
As evidence for this weighty statement, he again and solely cites himself – the same chapter in the same 2003 book.
In his table in that chapter he gives Confrontational Counseling a minus 183, ranking it #45 on the list of 48 interventions. That’s pretty low, but the other three evidence-impoverished interventions mentioned in this statement don’t even make the list, so they must be really, really low!
I have no experience at all with confrontational approaches to substance abuse treatment. My intuition (for what it’s worth) would lead me to agree that such approaches don’t have much impact, although in my travels in substance abuse recovery circles, I have definitely met people whose experiences would differ.
Nor do I have much personal experience with insight-oriented psychotherapy in that setting, but my bias (for what it’s worth) is that it probably won’t help people much until they have been clean and sober for a couple of years (at which time it might be “just what the doctor ordered” to prevent relapse!).
Nor has anyone ever made me go to AA meetings. But I will tell you this: I can’t count the number of times that I have been sitting in an AA meeting listening to a speaker who attributed his or her recovery solely to mandated meetings. It is so common in the AA culture that they have a euphemism for it: it’s called “a nudge from the judge.”
If Miller is right in ascribing such low impact value to this, what is going on here? Are these people delusional? Is it that they were really ready for recovery but didn’t know it so got themselves mandated to AA through some subliminal process?
How would Miller invalidate the experiences of these people?
I am genuinely curious.
The fourth thing on Miller’s list is acupuncture. He mentions it first, but I saved it for last because it is something with which I do happen to have a lot of experience. Those two articles I published – and that book I wrote – that’s what they were about. Acupuncture in the treatment of substance abuse.
Maybe the reason Miller does not ascribe a numeric scale or ranking to acupuncture in his table is that there were so many favorable clinical trials in the 1980s and early 1990s (Brumbaugh, 1993) that they would skew the numbers resulting from the poor clinical outcomes that followed.
I have first-hand knowledge of what accompanied that sad downward trend in the research outcomes, and it relates back to the issue of context.
In the first clinical trials evaluating acupuncture, the modality (a 3-5 needle ear protocol) was studied in the context of a treatment continuum, i.e. a residential detox for homeless men. The outcomes were very positive. Acupuncture advocates have never asserted that it is a stand-alone therapy; it works in concert with other therapeutic interventions, including medications, case management, cognitive therapy, and other things high on Miller’s list.
And yet the research studies increasingly and persistently began to look at acupuncture in a vacuum. One of the last studies involved cocaine addicts who were not involved in treatment or recovery programs at all, who were paid a cash stipend to come to acupuncture sessions in a university setting. These volunteer subjects presented their ears to a hole in a piece of cardboard in order to assure that the acupuncturist would not recognize the person who was receiving sham versus therapeutic acupuncture and to eliminate any relational factors that might alter the outcome of the study. No one spoke to these subjects. If the subject happened to ask if anyone knew of any recovery resources for cocaine addicts, no one could say anything lest it squirrel the study.
Dr. Miller says that he factors in the “scientific rigor” of the studies he uses to make his charts and report his findings. I’ll bet this study got really high marks for its rigor!
Speaking of scientific rigor versus common sense, here’s something interesting: An acupuncture study just published in (of all places) the Journal of Substance Abuse Treatment (Meade, 2010) looked at whether or not a form of electric acupuncture stimulation was effective in treating opiate addicts in an inpatient setting. The acupuncture was administered for in 30-minute treatments for four days along with prescribed drugs (a combination of buprenorphine and naloxone). Even though the declared intent of the study was to address the symptoms associated with opioid withdrawal, such as nausea, irritability, and insomnia, in order to decide if the 4-day treatment was effective or not, the researchers tested people to see if they had used opiates two weeks following discharge from the program!
So the presumption was that a treatment administered for 30 minutes for four days upon admission to an inpatient program might influence whether or not people were still abstinent two weeks after discharge.
Success at two weeks post-discharge is going to be influenced by far more variables than a procedure that was done for four days following admission. And yet such studies are – in Miller’s world – the gold standard that is used to determine what should and should not be done in treatment. (Ironically, this particular study found that those receiving acupuncture were more than twice as successful as the control group, and they also reported they were less bothered by pain and that they experienced greater improvements in overall health.)
Go figure.
I’m sure this study will prompt Miller to publish a retraction of his disapproval of the modality.
On a related subject, what does it really look like inside a treatment program that is doing rigorous, scientific, double blind clinical trials on substance abuse interventions? Where are these clinics? Do they represent all the kinds of clinics and programs where people get sober? Are they mostly based in university or VA hospitals? Who are the subjects? Are the only people who get studied those who are willing to volunteer for a (usually) government-funded research study and who are therefore willing (and able) to fill out all the reams of paper work and sign all the consent forms and waivers that will be required?
(That last one is a trick question. Of course they are.)
So, is that a typical substance abusing population?
Who knows?
Who knows anything, for sure?
We should probably be well-advised not to conclude things that cannot be supported by evidence and by experience and by common sense.
But if he wants to persist (and I am sure he will), here’s another thing that Dr. Miller can put on the bottom of his efficacy list:
Cats.
There have (so far as I know) been no double-blind clinical trials on the efficacy of having substance abusers interact with cats while in treatment.
I mention this because someone dear to me one time had successfully recovered from multiple addictions – alcohol, heroin, cocaine. She had gone through and failed numerous treatment programs, some of them very “high-end” famous ones in California, Arizona, Minnesota, and so on. She finally got sober in a women’s half-way house. They didn’t even have formal treatment, just peer support and community living. I asked her why that worked for her, what the difference was that helped her finally achieve long-term sobriety.
She said there was a cat who lived in that house, and it gravitated to her and began sleeping on her bed. She said that it was the first time in her life that she had experienced unconditional love. The cat didn’t care where she had been, what she had done.
My friend never drank or used again.
How’s that for impact?
We should study that.
But we can’t. You would have to have sham cats. And to make it double blind, the people couldn’t know whether the cat in their room was a sham one or really cared about them. You would have to keep that information from the cat as well. Someday science may be able to accomplish that (perhaps John Cameron could help), but it hasn’t done so yet.
* * *
A final thought: The way to diffuse EBP into the treatment milieu is to make it a condition of funding. Treatment programs, for the most part, do what they do not because they think it’s so great, but because it gets reimbursed. Inversely, programs don’t avoid things that work per se. They avoid things that don’t get reimbursed because they don’t have any resources to do them.
Some of the recent treatment grants from SAMHSA not only require EBPs, but urge very specific ones (thanks to the lobbying efforts of whom?). That means that if you want to apply for the money, you have to promise to do the EBP. No education or movies or acupuncture or mandated AA or loving kittens are to be included in these programs lest their fidelity be compromised.
The important questions are: (1) Are we absolutely sure that’s what we want? (2) Do we really know what we’re doing?
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