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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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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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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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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
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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
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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-
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Levine, H. G. 1978. The discovery of addiction: Changing conceptions of habitual drunkenness in America. Journal
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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
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BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
Popham, R. E., W. Schmidt, and S. Israelstam. 1984. Heavy alcohol consumption and physical health problems:
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characteristics. Journal of Studies on Alcohol 49:233-239.
Representative terms from entire chapter:
brief intervention
