I recently attended a training workshop presented by Gateway Foundation at the Adler School of Professional Psychology. The presenter, David Mee-Lee, M.D., was one of the editors of the criteria used by substance abuse counselors to guide placement into treatment. His “take-away” message was that treatment professionals need to become experts at meeting clients “where they are”… Aligning their treatment plan with the actual goals that motivate the client, rather than focusing on getting the client to accept the counselor’s idea of what is needed. This can be a little bit controversial, because the nature of addiction makes it hard for people to see their own situation clearly, even when they know they need to do something about the problems that alcohol or drugs are causing in their lives. Counselors have become used to having to work hard to break through layers of “denial,” as it’s popularly viewed.
Most people think of “rehab” when they hear of someone whose substance use has gotten out of control and is causing problems in their life. We hear of celebrities “going into rehab” – sometimes over and over again. The model program for this was a 28-day residential treatment setting, such as the type of residential treatment used at Hazelden and the Betty Ford Center. These programs evolved over the past 40 to 50 years, and are characterized by being rooted in the 12-step traditions of Alcoholics Anonymous and Narcotics Anonymous.
Many, if not most, of the counselors and treatment staff in these programs subscribe to the twelve-step philosophy, and many have had personal experience with addiction and recovery themselves. Some of the basic assumptions of this approach are:
- People usually need to “hit bottom” before they will accept help.
- Denial is a universal apect of the disease of addiction, and must be confronted and broken through before the addicted person can begin to recover.
- Recovery is a lifelong process, and the addicted individual will always be at risk of relapse, so the best that can be expected is “one-day-at-a-time” sobriety.
- For this reason, lifelong attendance at meetings is the only way to achieve and maintain sobriety, and any “falling away” from a recovery program is a sign of impending relapse, sooner or later.
These “old-time” attitudes and ways of running treatment programs endured because they worked better than anything else that was available, and my experience in the employee assistance field has brought me into contact with many of these treatment providers and counselors. They are sincere, motivated people who do great work and care deeply about their clients, and about improving people’s lives by sharing the inspiration and support that they have learned to foster among recovering people.
Recently, however, things have begun to change. In the 1980’s and 1990’s, the advent of managed care and the demand for evidence-based treatment led to insurers and referral sources expecting a more customized treatment plan for each patient, including clear demonstrations of the need for each level of care. The push for treatment in a less-restrictive environment, coupled with cost-containment efforts, led to more use of intensive outpatient and partial hospitalization programs. Some insurers stopped covering residential treatment altogether. There was a surge of interest in outcome research and evidence-based practice, which led to some studies that examined the value of “treatment matching” – that is, trying to give people the type of treatment that should best address their particular situation. At the same time, the American Society of Addiction Medicine published a manual that provided criteria for recommending various levels of care, from inpatient detoxification all the way down to preventive education.
Dr. Mee-Lee gave a very engaging presentation that emphasized the importance of motivational enhancement as the first step of engaging people in treatment plans that truly meet their needs. Granted, counselors’ experience leads them to know very well that addiction frequently follows patterns that are unfortunately “classic,” one of the hallmarks being that the person struggling with addiction desperately hopes to be able to have things go back to the way they were when he or she could drink normally, or use occasionally. A.A. even has an old saw about this type of wishful thinking, telling people who express the hope that they can be different that they suffer from “terminal uniqueness.” While there is some truth to this concept, this way of saying it may come across as belittling and likely to put people off when they need help the most. Rather, as Dr. Mee-Lee suggested, counselors should join with the clients’ goals, and invite them to move forward in setting new goals that they can achieve by working together. In the process, clients will gain hope, confidence, and the skills needed to make lasting changes.
This is the direction in which addiction treatment needs to move: rather than applying formulas for treatment, it means working with clients to mobilize their desire to change their lives and learn new ways of living, with support and help from caring professionals and others who have been there. Rather than applying a predetermined approach – even an “evidence-based” approach – treatment professionals will be expected to continually work with their clients to join together in planning treatment that works best for the individual. As Dr. Mee-Lee pointed out, the treatment plan may initially be a “keep my probation officer off my back” plan, which is OK at that moment. But eventually, the professional needs the skill and empathy to move the client to embrace a “make the changes that will ensure a healthy life and better coping” plan.
This shift in thinking may not be easy for all of us in the treatment field, but it will be interesting to participate in the growth of the field in the coming years.