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~ Our Vision Where there Is no vision, the people perish. -Proverbs 29:18 In the introduction to and summary of this study, the steering committee detailed the process by which it responded to its mandate. During this process much information was brought forward and is presented in considerable detail in the multiple chapters of this report, together with the recommendations that arose from it. As is the custom in such presentations, the material is divided into chapters, each of which covers an important aspect of the whole. Yet the whole itself also requires consideration. During the committee's prolonged and detailed examination of information on multiple aspects of the subject matter, an overarching view of the probable evolution of treatment for people with alcohol problems emerged with considerable clarity. Once this had happened, the overarching view guided the development of the report. Because it is difficult to understand the parts of the report without reference to the whole, the committee has decided to begin its exposition with a brief description of this view, which it has chosen to call its vision. From several possible definitions of "vision, the committee has selected one that dates from 1592 to convey its meaning-"a mental concept of a distinct or vivid kind; a highly imaginative scheme or anticipation" (Oxford English Dictionary). In choosing both the term and this definition of it, the committee deliberately underscores the subjectivity of its viewpoint. It recognizes that other groups of individuals considering the same material may develop alternative visions. The committee welcomes these alternatives as compatible with its belief that future progress can only benefit from the availability of differing viewpoints. Briefly put, the committee's vision is that the treatment of people with alcohol problems has undergone an historical evolution. From an originally and perhaps necessarily circumscribed focus, the base of the treatment enterprise has begun to broaden in a number of important ways, a development the committee believes should be encouraged. Yet together with, and largely because of, the development of a broader base, there is a concomitant need for a more structured approach to treatment. That structure takes the form of treatment systems, each of which may combine many important properties and functions of treatment into a coherent whole. In the balance of this chapter, which concludes Section I of the report, the committee will further describe its vision. The report then attempts in Section II to address questions that are often put to those involved in the treatment enterprise; they are not necessarily the most appropriate questions, but they are the ones most frequently asked (e.g., "Does treatment worked. In Section III, several critical aspects of treatment, such as assessment, are addressed, as well as the advantages of joining these aspects together into a carefully articulated whole. The needs of special populations, as defined by various structural and functional descriptors, are considered in some detail in Section IV. Financing, the crucial "bottom lines that has more frequently determined rather than facilitated the provision of treatment, is discussed in Section V. Finally, in Section VI, the committee discusses the multiple leadership initiatives needed for a fuller realization of its vision. 13

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14 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS A Brief History of Treatment As noted above, the committee's vision rests in part on a view of the development 1982 have been provided through a block grant mechanism to the individual states for administration. The growth of the private sector in treatment has been a feature of recent years (Yahr, 1988~. Thus, the treatment of alcohol problems in the United States can be traced back for about 200 years-a brief span by historical standards but it is, in many significant respects, a much more recent phenomenon. On account of the hiatus introduced by

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OUR VISION 15 Prohibition and the "Great War," treatment had in some respects to start from scratch following repeal in 1933. Alcoholics Anonymous, the oldest significant feature of the current scene, is but 50 years old, and the changes introduced by the Hughes Act and by private initiatives are even more recent. During the course of this study, the committee had an opportunity to examine much of the current treatment effort, and it was deeply and positively impressed. It is convinced that people seeking help with alcohol problems at present often receive effective and even invaluable assistance. Much, indeed, has been accomplished. But the historical record is as yet brief, and significant changes continue to occur. The evolution of treatment has not ceased but is ongoing. The committee would fix our current position with respect to the evolution of treatment by echoing Churchill: "Now, this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning." Broadening the Base The historical record also suggests that treatment for any problem tends to originate as a result of attention being drawn to severe cases. Initially, treatment consists of applying to these cases the existing remedies that are available when the problem is first recognized. As time passes, however, it becomes increasingly clear that (a) cases other than severe cases exist and (b) other methods can be used to deal with them. The history of the treatment of most problems follows this progression; diabetes, tuberculosis, and cancers offer illustrations. Thus, it is not surprising to find the same progression in the treatment of persons with alcohol problems. The committee has elected to refer to the principal target of therapeutic activities as alcohol problems, including, as necessary, appropriate modifiers for time course and severity (e.g., acute mild alcohol problems; chronic severe alcohol problems). This broadened frame of reference is discussed in Chapter 2; Chapter 10, which deals with assessment, discusses the multiple dimensions along which alcohol problems should be specified. It is now accepted that individuals experience many different kinds of problems around their consumption of beverage alcohol. Such problems range from the hyperacute to the severely chronic and from the mild to the extremely severe. They are manifest at different levels and in different patterns of alcohol consumption that in turn are associated with differing symptoms and with consequences in differing life areas. Alcohol problems are heterogeneous. There is not one problem but rather many problems. The committee believes that this broad range of problems requires the attention of a knowledgeable individual who can gather the appropriate information and make a reasonable decision about what to do (or what not to do). As will be further discussed in Chapter 9, these activities constitute an important aspect of treatment. It is also accepted that the individuals who manifest the problems are themselves diverse. These individual differences are important for many reasons; for example, they affect the selection of treatment. Different individuals prefer and may benefit from different kinds of treatment. Chapters 2, 10, and 11 discuss these differences, how they may be taken into account in the treatment process, and the improvements in treatment outcome that may result. The whole of Section IV of the report, "Special Populations in Treatment," also deals with this issue. As the field has developed over time, new treatment methods have been proposed and tested, with the result that there are now many different methods of treatment for people with alcohol problems. These methods are described in some detail in Chapter 3, and the evidence for their efficacy is discussed in Chapter 5 and the related Appendix B. Moreover

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16 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS additional personnel have entered the field over time-the development of the counselor's role is but one example-with the result that there are now many persons with differing backgrounds who are providing treatment in a variety of settings. Chapter 4 discusses these providers. Treatment that is provided must be paid for. Originally, it was either paid for directly by the individual who received it or provided as a charity by the treater. With the growth of a complex society, the payment issue has become much more complex, and there are now ninny differed ways in which treatment is paid for. Payment methods are detailed in Chapter 8, as well as in the related three chapters of Section V, "Aspects of Financing. Thus, there has been a fundamental broadening of the base of treatment with the passage of time. Originally, a restricted number of treatment options were applied to a relatively homogeneous group of persons with similarly severe problems by a small number of therapists who were reimbursed for their efforts in a restricted number of ways. Today, treatment involves a large number of very different people with very different problems who are treated in a variety of ways by a diverse group of therapists who are reimbursed for their efforts through multiple mechanisms. There is every reason to suppose that this evolutionary trend will continue, a course of development with which the committee is comfortable. Yet there is another sense in which the base of treatment has been broadened, and the committee believes this aspect of the evolution of treatment is worthy of special emphasis. Until quite recently, the treatment of alcohol problems was viewed as the exclusive province of a specialized treatment sector. Specialized treatment for alcohol problems is a vital and necessary component of the overall therapeutic approach. There has been increasing recognition, however, that it cannot constitute the whole of the therapeutic approach to alcohol problems. Particularly from epidemiological studies of the general population, it has become apparent that, although some people have multiple alcohol problems, most people who have alcohol problems have a small number of such problems (the relevant evidence on this point is discussed in Chapter 9~. Because they have few problems, they are likely to seek help for the individual consequences of their problems- for example, health consequences. Thus, many individuals will seek help from their physicians for "nervesn or "stomach trouble," or from their welfare worker for "family problems," or from their school guidance counselor for Trouble concentrating," without recognizing the critical role that may be played in such problems by excessive alcohol consumption. To considerations become critical under these circumstances. One is that the role of alcohol consumption in the genesis of such problems be identified by the individual to whom these problems are presented. The other is that the individual identifying the alcohol problem be able to deal with it directly through a brief intervention, without necessarily making a referral to specialized treatment. There is now very good evidence (see Chapter 9) that brief interventions may be effective for a large number of people with alcohol problems. Moreover, many such people will not accept a referral to specialized treatment. Without the option of brief intervention, an important opportunity to deal effectively with these individuals will be lost. In addition, because most individuals with alcohol problems are of this kind, an important opportunity will be missed for reducing the total burden of alcohol problems on society. This brief intervention strategy, which is discussed extensively in Chapter 9, in many ways represents the greatest degree of broadening the base of treatment. It posits that the elective reduction of the burden of alcohol problems cannot realistically be viewed as the sole responsibility of specu~lized treatment programs. Rather, the reduction of alcohol problems must be a much more broadly disseminated responsibility, involving a great many different personnel in a large number of different human services arenas, all of whom must learn to recognize such problems and intervene effectively.

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OUR VISION 17 In some quarters this conclusion will be viewed as surprising, but it is really quite straightforward. The burden of alcohol problems is a heavy one; the specialized treatment sector is necessarily limited in size and quite costly. The committee believes that only a shared effort can succeed in lifting this burden to any significant degree. For humanitarian and other reasons it is necessary to focus on those with more serious problems; but for practical reasons it is necessary to focus on those with less serious problems as well. Toward Treatment Systems If the base of treatment for alcohol problems needs to be broadened, the apex of treatment needs to be sharpened. In other words, although more needs to be done to deal broadly with people who have less severe problems, it is true at the same time that more reeds to be done to deal effectively with people who hare more severe problems. This conclusion, which the committee feels leads toward the development of treatment systems, is the outgrowth of many of the same considerations that lead toward the broadening of the treatment base. The committee's reasoning with respect to the specialized treatment of alcohol problems begins with the observation that alcohol problems are diverse and that they are manifested by very different kinds of individuals. This observation is as true of people with substantial to severe alcohol problems as it is of people with mild or moderate alcohol problems. As well, there are many different treatment approaches. A major conclusion from research on the outcome of treatment is that there is no one treatment approach that is effective for all persons with alcohol problems (see Chapter 5 and Appendix B). Several major consequences arise from these fundamental observations. First, differences in the problems presented and in the individuals who manifest them must be taken into account before a decision is made regarding which kind of treatment is most appropriate; this goal is accomplished through pretreatment assessment (Chapter 10~. Second, every possible effort must be made to ensure that each individual receives the kind of treatment most likely to produce a positive outcome for him or her; this goal is accomplished through a process of matching (Chapter 11~. Third, because treatment outcome cannot be assumed to be positive, it must be determined in all cases and on a regular basis (Chapter 12~. Logical as these considerations may be, pretreatment assessment, treatment matching, and the regular determination of treatment outcome are not at present being widely implemented. In addition, the multiple treatment options implied by these processes are not now usually available to individuals entering treatment. It is quite true that there is a need for further research into all of these activities, and also for research on the feasibility of implementing them on any scale. The committee believes, however, that implementation should not wait upon the final completion of an extensive program of research. Relevant research is well under way and, if the reasons for implementing these processes are compelling, as the committee believes they are, ways must be found to make them broadly available. To some extent, these critical processes have already been implemented or are planned to be implemented (see Chapter 13~. No doubt there are many different implementation scenarios. For example, one possible way to achieve the provision of pretreatment assessment leading to careful matching to a variety of treatment methods with regular determination of treatment outcome might be through the coalescence of individual treatment programs. Most programs offer only one kind of treatment. By joining together with other programs they could offer a greater variety of treatments. Their combined resources would also be better able to support the added processes of pretreatment assessment, matching, and outcome determination and would offer a more commanding position from which to garner the

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18 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS new resources that are likely to be needed. Some larger treatment programs might be able to restructure themselves internally to achieve the same end. The committee has formulated some suggestions for initiating these changes (see Chapter 123. Almost by definition, and irrespective of the scenario that is followed, such a restructuring will result in the formation of a treatment system, that is "a set or assemblage of things connected, associated, or interdependent, so as to form a complex unity; a whole composed of parts in orderly arrangement according to some scheme or plan" (Oxford English Dictionary). What this structure might look like is outlined in greater detail in Chapter 13 but will be briefly presented here. Figure 1-1 shows the committee's vision of the system toward which the treatment of alcohol problems is evolving. Community Treatment of Alcohol Problems *Other=Education, Criminal Justice, etc. Specialist Treatment of Alcohol Problems . _ _ _ ~ _ . Continuitv of Care 3 Comprehensive Assessment ~ 1 | Typ e "A" ~ | Intervention- ~e'~C": ~ | Intervention | \ I Type'~X'' L | Intervention | ~ Type "B" _ Intervention Type "D" lnt.~?rvent.inr~ ~I Feedback FIGURE 1-1 The committee's view of the evolving treatment system. All persons seeking services from community agencies are screened for alcohol problems. A brief intervention is provided by agency personnel for persons with mild or moderate problems. Persons with substantial or severe problems are referred for a specialized comprehensive assessment. Where treatment is indicated they are matched to the most appropriate specialized type of intervention. The outcome of treatment is determined, and feedback of outcome information is used to improve the matching guidelines. Continuity of care is provided as required to guide individuals through the treatment system. On the left of the diagram appears that portion of the treatment system that is optimally located within various agencies and organizations in the community that provide services and subserve other functions. The task of the community treatment sector (see Chapter 9) is to (a) identify those individuals within it who have alcohol problems; (b) provide a brief intervention for persons who have mild or moderate alcohol problems; and (c) refer to specialized treatment those persons with substantial or severe alcohol problems, or those for whom a brief intervention has proven insufficient. The operational location of the community role in treatment is diverse; it is partly in the health care sector, partly in the social services sector, and partly in the workplace, in educational settings, and in the

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OUR VISION 19 criminal justice arena. Implementation of this aspect of the system greatly broadens its base and is more related to the training of personnel in relevant techniques than to the coalescence of treatment programs described earlier. Although the available evidence suggests that direct and relatively straightforward treatment within community settings can deal effectively with a substantial proportion of the population of individuals with alcohol problems, others will need specialized treatment. Specialized treatment is shown on the right side of the diagram and is concerned with persons who have substantial or severe alcohol problems, as well as other persons for whom a brief intervention has not proven sufficient. As the diagram indicates, all persons who are referred are first provided with a comprehensive assessment and on that basis are matched to one or more of a variety of available programs. After treatment, follow-up interviews are conducted to determine the outcome of treatment. If individuals have achieved a positive outcome, no further therapeutic attention may be necessary. If the outcome has not been satisfactory, further treatment may be indicated, perhaps of a different kind. As the arrows indicate, outcome determination and redirection of the individual are the result of a process of reassessment. It is worthwhile stressing that t1ze determination of outcome provides a crucu~lfeedback function of the treatment system. Feedback allows the system to correct for any lack of treatment success, perhaps its most obvious function. But it also provides, even in instances in which treatment is successful, an ongoing check on the matching guidelines used to select treatment so that the guidelines can be continually reexamined and confirmed or modified in the light of known outcomes. In addition, the feedback of outcome results provides an accumulating record of experience with particular individuals and particular problems in particular treatments. This record ultimately can be used to guide the future matching efforts of the treatment system. One further function that becomes increasingly important when a relatively more complex system is approached by individuals with substantial to severe problems is continuity of care (see Chapters 13 and 20.) Although some individuals may be quite capable of negotiating the system on their own, others will be unable to do so. This determination can be made as part of the pretreatment assessment, and appropriate steps can be taken to provide for continuity, either through the use of special personnel (expediters, ombudsmen, patient advocates, etc.) or by other methods. There is also a need to assure continuity of care between the specialized treatment system and treatment in the community; for the most part this task can be undertaken by community providers. The contribution to continuity of care rendered by Alcoholics Anonymous and other elements of the mutual help network is noteworthy. Advice to the Reader Such is the vision of this committee regarding the treatment of persons with alcohol problems. It seemed to arise naturally from the premises that the committee developed, to offer a reasonable promise of improved care, and to provide pathways for guidance into the future. A vision has to do with the future; the definition chosen by the committee includes the phrase Ha highly imaginative scheme or anticipation." Because our vision for the future differs from the reality of the present, change will be required. To change to a new perspective, even when that change involves a broadening rather than a replacement of the current perspective, is often very difficult. There is a natural and even laudable allegiance to concepts that have served well and faithfully over a long period of time. Although the current perspective is rich and does not lend itself well to a simple summary, it may be said with some justice that at present alcohol problems

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20 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS are largely viewed as arising more or less directly from the relatively predictable and uniform actions of the drug, alcohol, on the human organism. Alcohol is a drug, and its direct, relatively predictable, and uniform actions on the human organism have been well documented (cf. Michaelis and Michaelis, 1983; Popham et al., 1984; Palmer et al., 1986; Institute of Medicine, 1987; Koob and Bloom, 1988.) Yet alcohol problems are experienced by specific individuals, who live and move and have their being within very different social, psychological, and cultural environments. The committee's view is that, although the interaction of the drug, alcohol, and the human organism may be a consistent part of alcohol problems, the alcohol problems are deeply and profoundly modified by a multiplicity of other factors that are highly relevant for treatment. The focus in this report, therefore, is on an expanded perspective that includes the actions of the drug alcohol, as well as the totality of the context in which those actions occur (see Chapters 2 and 3~. A change in perspective similar to that called for by the committee in dealing with alcohol problems has been advocated for medicine. In his forward to Kerr White's lhe Task of Medicine (White, 1988), Alvin R. Tarlov has written that the "prevailing paradigm" in medicine envisages disease as the end result of disordered molecular and biochemical processes. Such processes lead to cellular, tissue, organ and system disturbance or destruction, resulting in disease, a characteristic constellation of specific biochemical, physiological, and pathological anomalies. These anomalies are responsible for the specific loss of physical and other functions experienced by the patient and observed by the physician. Dissatisfaction with the prevailing paradigm as a complete explanation of disease and illness has arisen in the past couple of decades. Coming largely from behaviorists, a broadened paradigm of medicine has emerged out of the certain knowledge that one disease may be manifest among a group of patients in widely divergent ways and that illness as experienced by patients may be as highly individualized as fingerprints. The modern paradigm, not by any means intended by its protagonists to replace but rather to broaden prevailing thought, interacts disease with personal, social, and psychological factors to explain individual differences in illness. Despite face and experiential validity, the broadened paradigm has not achieved wide acceptance. (Tarlov, 1988:ix) In an appendix to the same book (White, 1988), a "patient-centered clinical method" (rather than one centered on disease) is viewed as responsive to such a change in perspective (McWhinney, 1988.) The reader will find that a similar approach to treatment is outlined in this report, particularly in Section III. It is an approach that is to some extent already under way (see Chapter 13~. Nevertheless, the committee would like to see a more direct, intentional, arid multifocal approach to the testing, refinement, and implementation of its vision. that is the fundamental recommendation of this report. A caveat should, however, be posted. Despite its commitment to its vision, the committee believes that further progress should be gradual rather than abrupt. Because what is proposed is an extension of, rather than a replacement for, what exists, the intent of the present report would be violated if it were used as an excuse for dismantling what is currently being done. Rather, the committee feels its vision should be used as a catalyst to inform and accelerate a process that has already begun. Its intention is to extend and

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OUR VISION 21 increas~not reduce~erv~ces to persons with alcohol problems, although with the extension and increase of senaces it sees the necessity of a redistribution of emphasis. The committee anticipates that reactions to its vision may be mixed. Some reactions will be positive and will lead smoothly to a close inspection of the much more detailed text that follows. Other reactions, however, may not be positive. The committee urges those who have an unfavorable response to this initial summary to read on. We suspect that in some instances you will be reassured. If you are not, you will at least have more substantial grounds for your objections. Although our vision emerged with some sense of inevitability from the deliberations of the group, we recognize that it is not the only possible vision. To the extent that our efforts serve to sharpen a different vision that contributes to the future of treatment, we will also consider that our work has been worthwhile. REFERENCES Alcoholics Anonymous World Services, Inc.1955. Alcoholics Anonymous. New York: Alcoholics Anonymous World Services, Inc. Bowman, K, and E. M. Jellinek. 1941. Alcohol addiction and its treatment. Quarterly Journal of Studies on Alcohol 2:98-176. Hald, J., and E. Jacobsen. 1948. A drug sensitizing the organism to ethyl alcohol. Lancet 2:1001-1004. Institute of Medicine. 1987. Causes and Consequences of Alcohol Problems: An Agenda for Research. Washington, D.C.: National Academy Press. Jellinek, E. M. 1943. Benjamin Rush's "An Inquiry into the Effects of Ardent Spirits upon the Human Body and Mind, with an Account of the Means of Preventing and of the Remedies for Curing Them." Quarterly Journal of Studies on Alcohol 4:321-341. Jellinek, E. M. 1947. Recent trends in alcoholism and in alcohol consumption. Quarterly Journal of Studies on Alcohol 8:142. Kobler, J. 1973. Ardent Spirits: The Rise and Fall of Prohibition. New York: G. P. Putnam's Sons. Koob, G. F., and F. E. Bloom. 1988. Cellular and molecular mechanisms of drug dependence. Science 242:715- 723. Levine, H. G. 1978. The discovery of addiction: Changing conceptions of habitual drunkenness in America. Journal of Studies on Alcohol 39:143-174. Maxwell, M. A. 1950. The Washingtonian Movement. Quarterly Journal of Studies on Alcohol 11:410-451. McWhinney, I. R. 1988. Through clinical method to a more humane medicine. Pp. 218-231 in The Task of Medicine: Dialogue at Wickenburg, K L. White. Menlo Park, Calif.: The Henry J. Kaiser Family Foundation. Michaelis, E. K, and M. L. Michaelis. 1983. Physico-chemical interactions between alcohol and biological membranes. Pp. 127-173 in Research Advances in Alcohol and Drug Problems, vol. 7, R. G. Smart, F. B. Glaser, Y. Israel, H. Kalant, R. E. Popham, and W. Schmidt, eds. New York: Plenum Press. Palmer, M. R., T. V. Dunwiddie, and B. J. Hoffer. 1986. Cellular mechanisms underlying differences in acute ethanol sensitivity: Effects of tolerance and genetic factors upon neuronal sensitivity to alcohol. Pp. 157-178 in Research Advances in Alcohol and Drug Problems, vol. 9, H. D. Cappell, F. B. Glaser, Y. Israel, H. Kalant, W. Schmidt, E. M. Sellers, and R. G. Smart, eds. New York: Plenum Press. Parrish, J., H. Lewis, M. Baird, G. Milliken, et al. 1871. Address to the People by the Directors, Pennsylvania Sanitarium. Philadelphia: Henry B. Ashmead.

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22 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Popham, R. E., W. Schmidt, and S. Israelstam. 1984. Heavy alcohol consumption and physical health problems: A review of the epidemiologic evidence. Pp. 148-182 in Research Advances in Alcohol and Drug Problems, vol. 8, R. G., Smart, H. D. Cappell, F. B. Glaser, Y. Israel, H. Kalant, R. E. Popham, W. Schmidt, and E. M. Sellers, eds. New York: Plenum Press. Tarlov, A. R. 1988. Forward. Pp. ix-x in The Task of Medicine: Dialogue at Wickenburg, K L. White. Menlo Park, Calif.: The Henry J. Kaiser Family Foundation. Terris, M. 1967. Epidemiology of cirrhosis of the liver National mortality data. American Journal of Public Health 57:2076-2088. White, K L. 1988. The Task of Medicine: Dialogue at Wickenburg. Menlo Park, Calif.: The Henry J. Kaiser Family Foundation. Yahr, H. T. 1988. A national comparison of public- and private-sector alcoholism treatment delivery system characteristics. Journal of Studies on Alcohol 49:233-239.