“Treatment sucks.”
No, those aren't the words of some grizzled, chronically relapsing heroin addict griping about being mandated to rehab for the umpteenth time. The above statement was delivered by Dr. Mark Willenbring, a prominent addiction psychiatrist and the former director of the National Institute on Alcohol Abuse and Alcoholism, at a conference of addictions professionals earlier this year.
His words struck a nerve with many who labor in the substance abuse field – a field increasingly divided between the abstinence-espousing, 12-step-promoting old guard, and the newer brigade of educated, liberal-minded providers who tolerate moderate substance use by clients (and who often take a less-than-reverential view of the AA-associated recovery movement).
Whether or not it “sucks,” few would deny that treatment is in a state of flux. Recent years have seen a number of important changes, notably the increased implementation of a technique called motivational interviewing, developed by Dr. William R. Miller and Dr. Stephen Rollnick a decade ago. Motivational interviewing – which eschews confrontational counseling tactics of the “sit down, shaddap, and listen, if you knew anything you wouldn’t be here” variety in favor of a subtler approach which utilizes open-ended questions designed to raise client awareness of their problems – is now widely accepted as standard practice in the field.
Less universally embraced is the still-controversial “harm reduction” philosophy, which posits that an individual with a substance abuse problem need not necessarily aim for total abstinence but should simply try to minimize – or reduce – the harmful consequences of drug and alcohol use. That sort of thinking is heretical to some counselors, many of whom have historically been persons in recovery themselves, and believe that abstinence is the only feasible long-term goal to encourage clients to pursue. Such conventionally-oriented counselors are often baffled, if not enraged, by the idea that addicts and alcoholics might be able to use or drink with impunity.
Oil and Water?
“You’ve had the advocates of traditional treatment and the advocates of harm reduction involved in these polarized debates,” says William L. White, author of “Slaying the Dragon: The History of Addiction Treatment and Recovery in America”(a must-read for anyone interested in the evolution of the addictions field). However, he contends that we are moving toward a time when these two seemingly oil-and-water approaches will be more integrated.
Says White: “What we are seeing now are traditional treatment providers asking, `Does harm reduction have any role within our continuum of care?’ And then, on the flip side, you have the harm reduction people asking, `Are there ways we can incorporate a more recovery-focused orientation to what we are doing?’”
Most people trace the roots of harm reduction to Europe in the ‘80s, where it grew out of the syringe exchange programs designed to halt the spread of AIDS among heroin users. This concept of “reducing harm” eventually spread to the U.S. Gradually, clinicians began tweaking the philosophy, adapting it to the treatment of alcoholism and other addictions. The new thinking: Going from drinking a liter of vodka to a half pint of vodka per day – or from taking 30 milligrams to 5 milligrams of Xanax daily – is real progress.
Dr. Andrew Tatarsky, who heads the New York-based Harm Reduction Psychotherapy and Training Association, is working to correct what he feels are widespread misperceptions about harm reduction, which he sees as the future of substance abuse treatment. “I think we are in the midst of a real paradigm shift, a sea change in our field,” he says.
“The principles that we call harm reduction are simply principles of good treatment,” he continues. “It emerged as a concept almost in opposition to and as a critique of the limitations of abstinence-based treatment. How can you kick people out of treatment for using [substances] if that is the issue they are in treatment for? How can you require people to become abstinent as a prerequisite for treatment?”
Relapse: An Inescapable Fact?
Dr. Tatarsky has a point. Anyone who works in substance abuse knows that chronic relapse is an ongoing, inescapable fact, and that some individuals cycle in-and-out of treatment for years. Many actually reject the idea of ever getting completely clean and sober. While a famous 12-step bromide holds that “half measures avail us nothing,” is it possible that, for some, half measures might constitute success?
That’s a question likely to be argued for some time to come on the mammoth playing field that constitutes substance abuse treatment in America. The Substance Abuse and Mental Health Services Administration (SAMHSA) publishes an annual volume, The National Directory of Drug and Alcohol Abuse Treatment Programs, which lists programs in all 50 states; it’s as thick as a phone book, and lists hundreds of rehabs, therapeutic communities, methadone clinics, and residential and outpatient programs. Clearly, treatment is here to stay.
But Dr. Willenbring is one of a growing number of individuals who are insisting that old modalities of treatment must change. He says that treatment as it currently exists is largely an anachronism – especially the prevalent 28-day inpatient rehab model, which he contends most people view as “onerous.”
“The whole notion of this burst of intensive therapy for people with a chronic illness is the wrong approach,” he says. “We need to redeploy our resources and upgrade treatment.”
In particular, he says, incorporating evidence-based practices (i.e., practices that have shown efficacy in research trials) into treatment is key to his vision of change. Using such empirically supported approaches in a system of chronic care management on an outpatient basis is the direction Dr. Willenbring would like to see the field moving towards. “We already have the tools to be able to treat alcohol and opioid dependence in an office-based setting with medication and brief support,” he says. Yet while he hopes such changes will be forthcoming, he doesn’t believe rehabs will be going the way of the dinosaur anytime soon. “[The rehab model] is very deeply entrenched,” he admits.
Of course, the insurance industry has already impacted rehabs – indeed, the entire field – in profound and troubling ways. Nowadays, providers and clients are increasingly at the mercy of the managed care companies, whose goal is to save money by rigidly monitoring treatment. It doesn’t matter if a provider thinks 28 days of rehab is warranted; if the insurance company says five days will suffice, five days it will be.
A Long Strange Trip
A brief look back at the history of treatment reveals how far things have come in the last sixty years. Prior to 1950, most alcoholics wound up detoxing on the “flight decks” (psychiatric units) of local hospitals (although those with the financial resources might choose to “dry out” at an upscale sanitarium). Heroin addicts, for their part, had a choice of kicking cold turkey in a jail cell or undergoing a “cure” at one of the two (now-defunct) federal narcotic hospitals in Lexington, KY, and Fort Worth, TX.
For alcoholics, things began to change with the opening of Minnesota’s Hazelden Foundation in 1949, arguably the earliest rehabilitation model treatment center (the pioneering High Watch Farm was established a decade before). Hazelden was predicated on the belief that teaching the 12 Steps of Alcoholics Anonymous constituted the most effective means of treating alcoholics, and, to this day, much of its literature remains soaked in the 12-step ethos. Today, Hazelden is a venerable and many-tentacled institution. Its legacy remains the ascendance of the rehab, a trend that took off in the sixties, and kicked into high gear in the ‘70s and ‘80s.
In the late-50s, the controversial upstart program Synanon was founded in California by a former AA member named Chuck Dederich to help heroin addicts. Though little remembered today, in the 1960s Synanon was a widely respected organization which drew laudatory articles from such publications as Time, Look, and The Saturday Evening Post, among others. It spawned a 1965 film, “Synanon,” starring Chuck Connors and Eartha Kitt.
Basically a drug-rehabilitation commune, Synanon was the de facto model for all subsequent therapeutic communities, from New York’s Odyssey House to San Francisco’s Delancey Street. It spawned such therapeutic advances as the marathon confrontational encounter group – as well as such punitive measures as shaving residents’ heads or forcing them to wear humiliating signs (or diapers!) for behavioral infractions.
Synanon devolved into a cult-like, secretive organization that, in the 1970s, ordered male members to undergo vasectomies, and decreed that all couples must “change partners” (jettison old romantic or marital relationships and form new ones). There was also a notorious case in which Synanon members placed a rattlesnake in the mailbox of a lawyer who had displeased the organization. It was no surprise when Synanon sputtered to an ignominious close in 1991.
Until a couple of decades ago, alcoholism and drug abuse were widely considered to be wholly separate problems. In spite of public cognizance of the rise of cross-addiction, distinct treatment modalities existed for alcoholics on the one hand, and for those who abused substances such as heroin, barbiturates, benzodiazepines, cocaine, or amphetamines on the other.
Indeed, in New York State, two agencies, the Division of Alcoholism and Alcohol Abuse (DAAA) and the Division of Substance Abuse Services (DSAS), functioned discretely until 1992, at which point they were finally consolidated into one entity, the Office of Alcoholism and Substance Abuse Services (OASAS). Even with that, the laws governing the funding and licensure of alcoholism and substance abuse services remained separate until 1999.
The Future?
Dr. Frank McCorry, director of the Office of New York City Operations for OASAS, believes it’s an exciting time to be working in substance abuse treatment. He says that OASAS is, by regulation, an abstinence-based system, but that it has lately been reevaluating harm reduction – a concept the agency was initially lukewarm to.
“There was an ambivalence toward how harm reduction would work in a recovery-oriented system,” he says. “There was a question of whether using harm reduction techniques might be more examples of enabling than actual counseling.”
Recently, Dr. Tatarsky was called in as a consultant to OASAS. But Dr. McCorry stresses that harm reduction is but one of many approaches the agency is taking a close look at in terms of new directions in treatment.
“I’m particularly excited about a new initiative we have called TOPS – Transforming the Outpatient System of Care,” Dr. McCorry says, promising that TOPS will create a new, more efficient “continuum of care.”
Says Dr. McCorry: “Essentially, the goal is to have a single outpatient system which is responsive to an individual’s treatment needs. We’re going to integrate medication-assisted treatment, co-occurring disorder treatment, recovery-oriented systems of care and peer related processes within every outpatient setting. Whether you show up in Buffalo or the Bronx, evidence-based practices will be available to you.”
No doubt providers and government overseers will continue to tinker with treatment ad infinitum. One thing’s clear: Whatever the future of rehabs, substance abuse isn’t going away. Perhaps the terrible inexorability of the American people’s ongoing battle with drugs and alcohol can be summed up by this bit of folk wisdom commonly passed on to fledgling substance abuse counselors: “You won’t get rich doing this. But you’ll never be out of work.”
Tom Sinclair is a Credentialed Alcoholism and Substance Abuse Counselor. He is employed by the Addiction Institute of New York.
