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4 Who Provides Treatment? Persons with alcohol problems receive care in a wide variety of health care, social services, educational, corrections, and specialty mental health organizations, as well as in organizations that specialize in treating alcohol and drug problems. Treatment is provided by personnel from a variety of disciplines, including physicians, social workers, counselors, and psychologists. This chapter provides an overview of the various types of providers and personnel that make up the existing treatment services network and reviews the services they provide within the continuum of care. Describing the System to Treat Persons with Alcohol Problems In recent years there has been tremendous expansion of both institutional and community-based treatment programs within traditional agencies (e.g., general hospitals, psychiatric hospitals, primary care clinics, family service agencies) and in nontraditional facilities (e.g., social setting detoxification centers, public inebriate shelters, drinking-driver programs, quarterway houses). There has also been a concerted effort to obtain increased acceptance for the treatment of alcohol problems within the mainstream of health care services; yet many of these newer agencies now treating persons with alcohol problems are not located in traditional health care settings. These agencies reflect the historical evolution of the field in this country in that the major impetus for expanded treatment originated with Alcoholics Anonymous and the recovered persons who established pioneering halfway houses (Pattison, 1974, 1977; D. J. Anderson, 1981; Saxe et al., 1983; Weisner and Room, 1984; Weisner, 1986~. There have been a number of efforts to describe the system that has evolved for treating persons with alcohol problems, but the difficulties that surround this task have prevented the formulation of an acceptable, comprehensive classification scheme that fully incorporates the developments of the past 20 years. As discussed in the previous chapter, the states, third-party payers, and key federal agencies use very different labels and definitions for the elements in the continuum of care; one result of this variability is the differing classification schemes used by funders to obtain data from treatment providers to monitor utilization and appropriateness, to evaluate treatment effectiveness, and to develop reimbursement strategies (Bayer, 1980; Wilson and Hartsock, 1981; Bast, 1984; Brown University Center for Alcohol Studies, 1985; Institute for Health and Aging, 1986; McAuliffe et al., 1988~. Confronted with a similar lack of a uniform national and state approach for describing relationships among the various service providers, D. ~ Regier and his coworkers (1978) divided what they called the ode facto mental health services systems into three major sectors: general health, other human services, and specialty mental health. Their goal was to provide an initial systematic description of the services provided to persons with behavioral and emotional problems in order to make analysis possible. This framework can also be used to describe the ode facto systems that has developed to treat persons with alcohol problems. Of most interest is Regier's view of the "specialty mental health sector." He and his colleagues defined this sector as including those facilities and practitioners that devoted themselves exclusively to the treatment of psychiatric disorders. The specialty mental health sector included a wide range of facilities that provided inpatient care, outpatient care, or both; these facilities ran the gamut from state and county psychiatric mental hospitals, through halfway houses for the mentally ill, to college campus mental health clinics. 98
WHO PROVIDES TREATMENT? 99 Originally, treatment services for persons with alcohol and other drug problems were considered to be part of the specialty mental health sector. Yet the Regier team in its categorization excluded from the mental health specialty sector all facilities that exclusively treated persons with alcohol problems; they also excluded those other special-purpose facilities that treated drug abusers and the mentally retarded. (However, persons with alcohol problems who were treated in mental health facilities were considered to be part of the specialist sector.) The omission from the specialty mental health services sector of specialty facilities treating only persons with alcohol problems reflected the changes that were taking place in the organization and financing of treatment for mental health, alcohol, and drug problems in the 1970s. In particular, this omission reflects the insistence that alcohol problems were not always a symptom of mental illness but a disease that required Primary treatment" within a specially designed continuum of care (Plaut, 1967; USDHEW, 1971; Grad et al., 1971; D. J. Anderson, 1981; Weisner and Room, 1984~. This perspective influenced some of the states (e.g., California) to ston treating persons with alcohol problems in state mental hospitals; however, other states (e.g., New York, Minnesota, Colorado) developed specialty units within their state hospitals (Diesenhaus and Booth, 1977; D. J. Anderson, 1981; Weisner, 1986~. Over the past 20 years, two overlapping yet distinct specialty sectors have emerged: the alcohol problems treatment sector and the drug abuse services system. Each sector appears to have different structural and dynamic qualities that are shaped by ideology and pragmatic survival needs (Weisner and Room, 1984; Cahalan, 1987~. If one applies the framework developed by the Regier team (1978), then the specialist alcohol problems treatment sector comprises those facilities and practitioners that treat only persons with alcohol problems. In fact, what has emerged is a distinct network that embraces not only facilities and practitioners but also funding agencies, regulatory agencies, interest and advocacy groups, referral agencies, trade associations, and professional societies linked to the treatment providers in the alcohol problems sector. In addition to the independent facilities of the specialist alcohol problems sector, provider organizations that belong to each of the other three sectors identified by the Regier team (i.e., general health, other human services, specialty mental health) have also developed specialized programs for treating alcohol problems. Currently, however, more is known about the treatment of alcohol problems in the specialty sector than in these other nonspecialist (i.e., non-alcohol specialty) sectors. He committee suggests that more accurate descriptions arid studies of each of these sectors be developed as a first step toward formulating recommendations for changes in practice and r-wing. These sectors are briefly described in the paragraphs below. Treatment of Alcohol Problems in the Nonspecialist Community Sectors Following the definitions of Regier and colleagues (1978), the general health care sector comprises all of those facilities and practitioners that offer treatment for alcohol problems within their regular programs or practices. It includes the primary care clinician-whether pediatrician, general practitioner, internist, nurse practitioner, physicians assistant, or family practitioner-who attempts to care for a person who is concerned that she or he may be drinking too much. In this instance, there may be physical problems that bring the person to the attention of the care giver and that become the focus of the treatment, rather than the drinking behavior itself. There is some evidence that the majority of persons seen in this sector are women (Weisner, 1986~. The management of the person with alcohol problems may consist of prescribing a minor tranquilizer (e.g., Valium) because the reason given for the excessive drinking is anxiety, brought on by stress
100 BROADENING IXE BASE OF TREATMENT FOR ALCOHOL PROBLEMS at home or at work, or both, and providing supportive counseling. The proportion of patients seen for this type of treatment is unknown. As discussed in Chapter 9, estimates have been made and studies conducted in various health clinics and other primary health care facilities of the number of persons in treatment who are experiencing alcohol problems. However, these studies vary substantially in the methodologies they use to determine the nature and severity of problems, and they rarely review the treatment that was received. P. D. Cleary and coworkers (1988) reported on a study that evaluated the ability of primary care physicians to identify and address their patients' alcohol problems. Although physicians were aware of the problems in 77 percent of the serious cases and in 36 percent of the less serious cases, they did not routinely address them. The need to improve physician education in identifying and treating alcohol problems is well recognized, and efforts are under way to provide such improvement (see the discussion later in this chapter). The general health sector also includes the short-term general hospital that has no designated unit for detoxification or rehabilitation. It may be that more persons with alcohol problems may be treated within this sector than are treated in the specialty sector (Harwood et al., 1985; Davis, 1987~. Their treatment, however, is likely to be limited to detoxification without rehabilitation or to treatment of the alcohol-related physical problems. The general hospital without a designated detoxification or rehabilitation program nevertheless can develop a screening and intervention program to increase the number of persons with alcohol problems who are identified, counseled, and referred (if necessary) to the appropriate specialist treatment (Lewis and Gordon, 1983; Williams et al., 1985). The Roger Williams General Hospital in Providence, Rhode Island, initiated such a r~ro~ram. site visited bv members of the committee, in which a multidisciplinary consultation team screens all admissions and assesses those that are found to have alcohol or drug problems, or both. The team is able to identify approximately 10 percent of the hospital's admissions as having alcohol or drug problems. The team then intervenes with an assessment of the patient's problems, followed by advice and referral to specialist treatment when indicated. Most of the persons identified by the screening procedures do not have a previous alcohol problem diagnosis but did have a medical or social complication directly related to alcohol intoxication or dependence. More than 80 percent of those referred for further care followed through with their first treatment appointment, usually in an ambulatory clinic (Lewis and Gordon, 1983; Williams et al., 1985~. lye committee considers this type of program worthy of replication and rigorous evaluation. The New York State Division of Alcoholism and Alcohol Abuse is currently providing grants to eleven general hospitals to carry out such screening and interventions (New York State Division of Alcoholism and Alcohol Abuse, 1989a,b). More efforts of this kind are needed. Investigation of Regier's second sector, Other human services, finds similar activities occurring. This sector embraces social services, correctional facilities and programs, and educational agencies in which efforts are made to work with clients, residents, inmates, students, and others who have problems with alcohol. Many correctional institutions that have no organized program encourage volunteers from Alcoholics Anonymous (AA) to come and work with their inmates, holding AA meetings within the institution and attempting to link those who are released with a formal treatment program or a sponsor, or both. Educational agencies may also provide services. Many school districts have established student assistance programs (SAPs) to work with youth at who are risk for or are already experiencing problems with alcohol and other drugs (G. L. Anderson, 1979; Morehouse, 1984~. Some SAPs are linked to a district's health program; others are linked to its school counseling program; still others may be freestanding. The approaches used by various school districts may vary, but there is a common theme that the treatment of alcohol problems is secondary to the agency's main educational
WHO PROVIDES TREATMENT? 101 mission. Thus, the focus of most SAPs is identification and referral. The treatment offered is most likely to be a brief intervention (e.g., rap groups, peer helper programs, education) provided by guidance counselors, school psychologists, social workers, and, increasingly, specialist substance abuse counselors (USDHHS, 1987b). Students who experience low or moderate levels of alcohol problems are treated within the educational sector; those who are identified as having more severe problems are referred to the alcohol problems specialist sector, often through the juvenile justice system. The extent of the services offered through SAPs is largely unknown, and for the most part, these programs have not been rigorously evaluated. The specialty mental health care sector, Regier's third category, includes those mental health practitioners and facilities that offer treatment for alcohol problems within their regular programs or practices. The sector includes the psychiatrist, psychologist, psychiatric social worker, psychiatric nurse, and marriage and family counselor who attempts to treat a person who has been referred either for a drinking problem or for another psychiatric problem. In some instances there may be independent comorbid problems; in others, one difficulty may have contributed to the other. Treatment is likely to consist of prescribing an antidepressant, antianxiety, or antipsychotic drug and providing supportive or insight oriented psychotherapy. As discussed in Chapter 3, the vehicle for providing such psychotherapy (individual, group, or family) may vary with the therapist's discipline and ideology. This sector also comprises the public or private psychiatric hospital that has no designated unit for withdrawal or rehabilitation but that admits persons with dual psychiatric and alcohol problems or persons with alcohol problems only to a general psychiatry ward. In addition, the specialty mental health care sector includes those community mental health centers, psychiatric outpatient clinics, and sheltered workshops that have no designated units but that do not exclude persons with alcohol problems. The extent of the services provided to persons with alcohol problems in this sector is largely unknown. Treatment in the Specialist Alcohol Problems Sector This sector includes those facilities, those units within larger facilities, and those private practitioners that concentrate solely on the treatment of alcohol problems and that provide organized programs of care for persons who require any or all of the treatment stages identified in Chapter 3. The term facility is used rather than hospital because many treatment services are now offered in settings that are not organized or licensed as general or specialty hospitals or as other health care agencies (e.g., neighborhood health clinics). Some of these facilities are freestanding residential programs, outpatient clinics, and day programs that may be licensed by the state alcoholism authority or by the state social services agency rather than by the state health facilities licensing agency. There is no national standard for making these differentiations, a situation typical in other health care areas as well. Rather, facility and program licensure is seen as a state regulatory function. The specialist sector can be broken down further according to attributes that affect organization and service delivery. The first grouping is those practitioners and organizations that treat only persons with alcohol problems; the second is those organizations and practitioners that have a specialty unit with a structured program which is embedded within a larger organization or practice. Examples of components that constitute the first grouping are the halfway house that admits only men who have completed a hospital or residential primary rehabilitation program and who are determined to be in need of continued support in a residential setting (i.e., extended care); the outpatient clinic that provides alcohol education and intervention services to persons
102 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS convicted of a drinking-related traffic offense; and a 58-bed specialty hospital that provides primary rehabilitation to persons who have been detoxified and medically stabilized in a general hospital. Examples of the second grouping are the 250-bed not-for-profit community hospital that has a discrete 20-bed alcohol rehabilitation unit managed by a national for-profit firm; the 100-bed private psychiatric hospital that has one 30-bed ward offering a rehabilitation program and a second 30-bed unit offering a program dedicated to the treatment of dual-diagnosis patients (i.e., those with coexisting psychiatric syndromes); and the minimum security correctional institution that offers a three-week primary rehabilitation day program for inmates that continue to reside in their cells or dormitories. Another categorization of the specialist sector that can be made is to group practitioners and programs that treat only persons with alcohol problems and practitioners and programs that treat persons with alcohol or other drug problems. In recent years, the number of such combined programs has been increasing (Reed and Sanchez, 1986; NIDA,~lAAA, 1989~. Recent national surveys of treatment facilities have found that most persons are now being seen in combined alcohol and drug units, although this percentage varies by setting and by state. Many states now have an overwhelming majority of combined units reporting data on service delivery (e.g., Pennsylvania, Louisiana, Michigan). Only a few states have a greater number of alcoholism-only units reporting (e.g., New York, New Jersey, Rhode Island) (Butynski et al., 1987~. What is clear is that there has been a definite increase in the number of combined programs and that many units that formerly admitted only persons with alcohol problems now also admit drug abusers. What, if any, impact this change has on treatment availability and accessibility for persons with alcohol rather than drug problems remains to be determined. The specialist sector can also be subdivided according to the type of population that a given group of providers serves. The populations seen in different facilities may differ on important sociodemographic and clinical variables (e.g., Kissin, 1977b; Kissin and Hansen, 1985; Research Triangle Institute, 1985; Weisner, 1986~. An early study by Pattison and colleagues (1978), which has been replicated a number of times, compared the population characteristics at four different facilities: (1) an aversion conditioning medical model hospital program, (2) a mental health outpatient clinic, (3) a social model halfway house, and (4) a county police work rehabilitation center. The persons served in each of the facilities were found to differ along a continuum of social competence; those treated at the aversion conditioning hospital were the most socially competent and stable and required fewer additional supportive services to achieve and maintain a positive treatment outcome; those served in the police work rehabilitation program were the least socially competent and stable and required many additional supportive services to achieve and maintain a positive outcome. Some of the differences observed among the populations in different facilities appeared to be caused by ideological considerations; others, by funding source policies; and still others, by community pressures. Research on the relationship of treatment ideology and organization to outcome is sorely lacking (e.g., Gilbert and Cervantes, 1986, 1988; National Council on Alcoholism, 1987; Wallen, 1988~. These earlier studies should be expanded and extende* the evolution of the specialist and nonspecialist alcohol problems treatment sectors should be monitored to ensure that the various special populations that might use these services are riot excluded from obtaining the resources they require (see Section IV). A number of other researchers have contributed to the discussion surrounding specialist and nonspecialist sector treatment settings. Saxe and colleagues (1983) developed an overview of treatment settings as part of their review of the cost-effectiveness of treatment for alcohol problems. This effort was an important first step toward developing a taxonomy that can be used to match persons with alcohol problems with the appropriate
WHO PROVIDES TREATMENT? 103 type of care at each stage of recovery. The Saxe team described four types of settings: inpatient, outpatient, intermediate, and other. The discussion below uses the Saxe taxonomy to describe treatment settings found in the specialist alcohol problems treatment sector. Ir~pa~ie~ Treater Se~ir~gp; The inpatient setting in Saxe's taxonomy was further divided into hospital and freestanding residential categories. Three types of hospital settings were identified: general, psychiatric, and aversive conditioning. The general hospital category was subdivided even further by the type of unit-detoxification or rehabilitation. (The type of unit here corresponds to treatment stage as described in Chapter 3.) However, Saxe and his coworkers did not specify types of units for the other inpatient settings or for outpatient settings, a gap in their framework that should be addressed because setting and stage of treatment are not necessarily linked. An additional hospital category is the alcoholism or chemical dependency hospital, which includes the aversion hospital noted by the Saxe team; 58 such hospitals were identified in a recent American Hospital Association (1987) survey. The survey also identified 874 general and other special hospitals that claimed distinct treatment units (15 percent of the total federal and nonfederal hospitals reporting) and 165 psychiatric hospitals with separate units (31 percent of those reporting). The largest number of hospital units were in California and Texas, although the states with the highest rates of beds per capita were New Hampshire and North Dakota (see Chapter 7~. Freestanding residential rehabilitation facilities, the second major type of inpatient setting described by the Saxe team, may carry out rehabilitation only, detoxification only, or a combination of both. Freestanding alcohol rehabilitation facilities vary in their relationship to hospitals as described in the NIAAA-sponsored classification discussed in Chapter 3 (Bast, 1984~. They can be a wholly owned unit located offsite or in a separate building on the sponsoring general hospital's grounds. For example, California's Betty Ford Center is housed in a separate building on the grounds of the sponsoring community hospital; it is licensed as a specialty chemical dependency rehabilitation hospital, a category unique to California (J. Schwarzlose, Betty Ford Center, personal communication, December 18, 1987~. Freestanding rehabilitation facilities can also be independently owned and maintain an agreement for backup by a hospital for detoxification and the treatment of acute medical problems. The rehabilitation center can carry out detoxification in a separate designated unit or as part of the rehabilitation unit. Many of the states fund or operate freestanding detoxification centers that were initially developed to replace the jails in which public inebriates were placed to sober up (DenHartog, 1982; Diesenhaus, 1982; Finn, 1985~. These facilities may follow either the medical model or the social model. Referral systems for detoxification vary from community to community as a function of the resources available and the community's level of acceptance of the social model or mixed medical and social model (see Chapter 7~. Most communities, however, have two parallel systems, a dichotomy based primarily on whether the available funding sources recognize social model detoxification programs as eligible providers. Such a division also reflects the continued identification of social model centers with public inebriates, the homeless, and indigents (Diesenhaus, 1982; Sadd and Young, 1986~. In addition to their relationship to hospitals, freestanding alcohol detoxification and rehabilitation facilities also vary in their licensing status from state to state; in some states, freestanding facilities can now be licensed as specialty hospitals (e.g., California's chemical dependency rehabilitation hospitals). Some notable freestanding alcohol treatment centers (e.g., Hazelden in Minnesota; see Chapter 3) contain differentiated detoxification and rehabilitation units and in some instances have multiple licenses for their acute care units and their primary care units.
04 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Outpatient Settings In recent years, the hospital-based or freestanding specialist outpatient clinic has become a major locus of treatment for alcohol problems. Outpatient treatment settings include traditional outpatient clinics that offer individual, group, and family therapy and clinics that offer f~xed-length day or evening rehabilitation programs. These fixed-length primary care outpatient programs are often based on the traditional Minnesota model inpatient programs. Harrison and Hoffmann (1986) described three such programs as part of a study comparing the effectiveness of inpatient and outpatient primary rehabilitation. Outpatients attended 20 primary treatment sessions in the evening following work. Each session lasted approximately three hours and typically included a lecture and one or two group therapy sessions. Family participation varied somewhat, ranging from nightly participation in the program to one night per week involvement in family groups and other activities. nAftercare~ followed the completion of the primary care phase of treatment and consisted of weekly sessions for patients and Significant others" at the programs along with referral to Alcoholics Anonymous. The three programs differed in the amount of formal aftercare provided; one provided up to six months; another, a minimum of six weeks; and the third, a minimum of eight weeks. Intermediate Settings The day treatment or intermediate setting noted by the Saxe team in its taxonomy has not been given sufficient attention by funders despite studies that have shown it can be used effectively at each stage of treatment (Lebenlutt and Lebenluft, 1988~. As a result, there is no standard definition of day treatment, although it has been differentiated from standard outpatient treatment. In general, day treatment has been suggested as an alternate setting for primary rehabilitation, although there have been instances in which its use has also been advocated for detoxification, extended care, and relapse prevention (e.g., Kolodner, 1977; McLachlan and Stein, 1982~. In day treatment, persons with alcohol problems participate in a structured program for most of the working day (usually a minimum of four hours for a minimum of three days a week) for a set number of weeks. This schedule contrasts with those of most outpatient programs, in which the person generally attends one or two sessions a week for an open-ended period of time. It is not known how many day treatment programs are currently in existence across the country. One reason for the paucity of information is that the day hospital category has been included in the outpatient category in the most recent National Drug and Alcohol Treatment Unit Survey (NDATUS; see the discussion later in this chapter) (USDHHS, 1987a). An earlier study by Frankel (1983) reported on a survey of 14 day treatment programs that were identified using the definition contained in the 1980 NDATUS (NIAAA, 1981~. The programs Frankel reviewed were selected from the 156 day care programs identified in that survey and tended to fit the psychiatric variant of the medical model (i.e., have a psychological orientation and use psychotropic medications in treatment); indeed, 11 of the 14 programs used DSM-III concepts and criteria (see Chapter 2) for setting admission standards. The use of DSM-III diagnoses may have been related to the programs' apparent focus on employed adults with health insurance. (Many publicly funded social model specialty treatment programs that receive categorical state and block grant funds through the state alcoholism agency do not use DSM-III or ICD-9 diagnoses iLawrence Johnson and Associates, Inc., 1983; Lewin/lCF, 1988a,b]~. This informal survey revealed a great deal of program variation in program duration, which ranged from 11 days to 18 months. Shorter programs included an aftercare outpatient component; the specifics of the various aftercare programs were not reviewed by Frankel. All 14 programs used a structured Program schedule that included alcohol ~, ~ education through films and discussions, as well as ~nolv~oual, group, and family counseling. All of the programs also required or expected participation in Alcoholics Anonymous. The other components of the programs varied significantly, ranging from a highly behaviorally oriented program to more traditional Minnesota model primary care approaches. A
WHO PROVIDES TREATMENT? 105 number of the programs met at night in four-hour sessions so that the person in treatment could continue working during the day. Several of the programs reviewed by Frankel were day treatment programs that were sponsored or operated by employee assistance programs (see the discussion under "Other Treatment Settings" later in this chapter). One such effort was the United Technologies Employee Assistance Program, which developed and operated its own day treatment program as an alternative to costly hospital-based primary rehabilitation programs and what it considered to be ineffective, one-session-per-week outpatient programs (Bensinger and Pilkington, 1983; Frankel, 1983~. The program ran 5-l/2 days per week, offering an intensive course of seminars, psychotherapy, and AA meetings at the treatment facility (two per week) to selected employees who were identified and referred by EAP counselors as individuals whose needs were appropriate for this level of rehabilitation care. Two days per week in the program were designated as family days; significant family members were encouraged to participate, and a weekly Al-Anon meeting was held at the treatment facility. Clients and spouses were expected to attend additional outside AA or Al-Anon meetings while in the program and to continue in an AA group once they had been discharged. The planned "stay" was two weeks, but it could be shortened or lengthened according to individual needs. For those needing detoxification and medical treatment, coordinated services were available at an affiliated detoxification unit in a nearby general hospital. Aftercare consisted of work site meetings with the EAP counselor as well as participation in AA groups. One of the great attractions of the day treatment concept, both for persons with alcohol problems and, indeed, for any psychiatric and medical patients, is its lower cost compared with inpatient treatment (whether in a hospital or in another residential setting). Day treatment or day care has also been proposed as an alternative to long-term care in a skilled or intermediate-level-care nursing home for the chronically physically and mentally impaired and for the frail elderly. Those who advocate use of the day-care alternative have developed similar formulations of the issues involved, whether the focus is treatment of the person with alcohol problems, or treatment of the physically or mentally ill. Dibello and colleagues (1982) suggested that psychiatric day-care programs, including those that serve people with alcohol problems exclusively, be classified into four major types according to which needs are served: (1) crisis support programs for individuals with acute phase disability who exhibit dramatic and serious symptoms and who require stabilization services to return to their presymptomatic state; (2) growth treatment programs for relatively stabilized persons with residual dysfunction who require habilitation/rehabilitation services to improve their interpersonal and vocational role performances; (3) maintenance-supportive treatment programs for persons with chronic problems who are stabilized and who require long term continuing care and support to prevent deterioration and relapse; and (4) diagnostic programs for persons who require direct observation over a significant period of time to identify problem areas and formulate a treatment plan. The first three types of programs in the Dibello scheme are similar to the the three major stages or phases (acute intervention, rehabilitation, and maintenance) in the committee's model of the stages of treatment for alcohol problems described in Chapter 3. The fourth type, diagnostic programs, is also included (as a component of the assessment phase, a necessary part of the continuum of care and the committee's treatment stages model). The use of day care as a less expensive alternative to hospital care can be justified for "selected" individuals who need crisis stabilization (acute intervention) and growth treatment (rehabilitation). Day-care programs can also reduce costs by shortening the length of hospital stays when they are used as a transition from hospitalization to independent community living for patients who need maintenance-supportive care (extended care and relapse prevention) in order to avoid relapse. . .
106 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Some day treatment efforts have been directed toward a particular special population (see Section IV). Zimberg (1974, 1983) described a pilot day-care program targeted to the needs and lifestyle of the "black socioeconomically deprived alcoholic" as part of a comprehensive program offering ambulatory and hospital detoxification, a halfway house, medical treatment, and vocational counseling. However, neither this model nor any of the other day treatment variants described above has been widely disseminated and replicated or evaluated, despite several studies suggesting that, for undifferentiated groups of persons needing treatment for alcohol problems, primary care in an intermediate, or day-care, setting is just as effective as inpatient Drimarv care in a hospital or other tiptoe of residential setting. One such study that became an important basis for policy development was a comparison of inpatient and outpatient treatment carried out on behalf of the Minnesota Chemical Dependency Program Division (Harrison and Hoffmann, 1986~. Using a quasi-experimental design (because clinical realities and pragmatic considerations precluded the use of random assignment), this study contrasted four-week inpatient primary care at two facilities with four week-outpatient primary care at three facilities. All five of the programs reflected the Minnesota model of treatment and were organized around the philosophy and 12-step recovery program of Alcoholics Anonymous. They were also homogeneous in methods and intensity. Lectures and group sessions were the primary components of the rehabilitation approach; the AA variant of the disease model of chemical dependency was the source of the educational content of the lectures, films, and discussions. Total abstinence from all mood-altering chemicals was the goal of treatment for all five programs. Harrison and Hoffmann found that there were no differences in outcome for subjects in the two conditions who were matched for number and severity of their alcohol-related symptoms and impairments. Despite some limitations as a result of sampling restrictions, the study's findings were an important contribution to the policy changes adopted by the Minnesota legislature in creating its consolidated funding strategy. This approach, which is discussed in Chapters 18 and 20, uses a single method to match persons to the appropriate level of care for treatment paid for with state-administered funds. Similarly, Longabaugh and colleagues (1980, 1983) reported on the results of a study in which persons undergoing detoxification were randomly assigned to an inpatient or an equivalent partial hospitalization primary rehabilitation experience. Day hospital patients lived at home and commuted daily to the hospital to attend its Problem Drinker Program (PDP) (McCrady et al., 1985~. Inpatients resided in one of the hospital's patient care units and walked to the same program; inpatients also participated in other activities in the unit's therapeutic program. The study found that persons treated in the partial hospitalization program functioned as well or better than their inpatient counterparts on all critical measures of treatment outcome. The committee visited the program and found the PDP to be a highly structured, behaviorally oriented approach that uses the principles of social learning as its underlying theoretical basis. Like the majority of behavior therapy variants of the psychological model, the PDP begins with a thorough assessment of the behavioral patterns associated with drinking and with a functional analysis of the person's urges to drink and his or her drinking episodes (i.e., behavioral chains). The program uses group sessions to teach patients how to carry out the functional analysis and to set specific goals for behavioral change. Educational sessions and materials deal with the negative consequences of unwise alcohol consumption and common behavioral patterns that are associated with excessive drinking. Volunteers who have overcome serious drinking problems serve as role models, modeling specific behaviors that are designed to reduce drinking. Planned activities, contingency contracting, and social skills training offer practice in carrying out alternative --rid or
WHO PROVIDES TREATMENT? 107 behaviors. Married patients participate in couples groups; in addition, a relatives workshop focuses on reinforcing positive behavior, decreasing family protection of the patient's drinking, and coping with relapses. When appropriate, meetings are held with employers to establish specific contingencies (in terms of work consequences) that will result from drinking and non-drinking behavior. The PDP is an ongoing program that receives reimbursement from most insurers but that has not been extensively replicated elsewhere despite its demonstration of potential cost savings (McCrady et al., 1986~. The committee sees an expansion of intermediate care programs such as the PDP as an important element in increasing treatment availability. Efforts to replicate such programs are indicated but appear to require additional resources, as well as, a series of clinical trials with various populations and unit locations, to persuade practitioners and funders of their unique value. The combination of primary care, and extended care when needed, and maintenance in the same program seems to be related to successful outcome as shown in a number of studies and suggested by several researchers; however, translation to clinical practice may require additional clinical trials as well as modification of current financing mechanisms (McCrady et al., 1986~. Often, halfway houses are also considered to be intermediate care settings. They have most frequently been described as transitional residential living facilities for persons who have completed primary treatment but require additional support and treatment to maintain their initial gains (e.g., Rubington, 1974; Berman and Klein, 1977; Armor et al., 1978; Orford and Velleman, 1982; Pattison, 1985~. In this sense, they tend to be used as extended care for less socially competent persons who require additional support to achieve and maintain a positive outcome. Confusion is created, however, because the same label had been applied to facilities that also offer primary care services and to extended care and maintenance services. New terms have been introduced to differentiate among the various services offered by these facilities (e.g., quarterway homes, domiciliaries, alcohol-residences, recovery homes). Thus. there is no uniform definition among the states of the halfway house and the services it offers. Some states view it solely as a setting that provides a supportive, alcohol-free living environment; any ongoing formal treatment (extended care or maintenance) must be delivered elsewhere. Other states require that halfway houses be professionally staffed and provide formal treatment. Private and public health insurers tend not to recognize halfway houses or recovery homes (the term used primarily in California) as eligible providers, and they frequently do not provide coverage for primary care, transitional care, extended care, and maintenance activities provided by these facilities (see Chapter 18~. Again, studies are needed of the service profiles and outcomes associated with different paths through the alcohol problems treatment system that will determine the appropriate role of such facilities and the propriety of coverage for their activities. Other Treatment Settings The committee has chosen to discuss under this rubric several areas of treatment provision that cannot appropriately be subsumed under the earlier treatment setting categories (although these areas may include elements or components that characterize those settings). The treatment programs to be discussed include those operated by the Salvation Army; self-help groups-in particular, Alcoholics Anonymous; drinking driver programs; and employee assistance programs. The treatment programs operated by the Salvation Army are one such example of the complex residential treatment services that have evolved to provide a continuum of care within one facility (Stoil, 1988~. Originally thought of as halfway houses, these programs are a mixture of the social and medical models, although the Salvation Army tends to see itself more as a social service sector agency with a medical unit than as a specialty alcohol problems treatment sector agency. Its programs provide social support, vocational rehabilitation, and medical services, along with primary treatment, to those persons with alcohol problems who are seen as among the least socially competent and ~7
108 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS stable and who have the poorest prognosis. It is estimated that the Salvation Army treats more than 70,000 persons each year. Its Harbor Lights or Social Rehabilitation programs serve primarily men (often skid row residents or homeless persons) who have few personal or economic resources and for whom treatment must indude additional supportive services. Salvation Army programs place a strong emphasis on vocational training and spiritual counseling and are still often viewed as halfway houses because of their target population and their emphasis on job placement and retention occurs concurrently with attempts to modify drinking behavior through various modalities (e.g., AA meetings, monitored They typically offer a longer term ul~;rvenuan mat comprises an 1nltlal primary care phase and an extended care program. Se1J-help groups Self-help groups, primarily Alcoholics Anonymous (AA), Al-Anon, and Alateen, are a significant segment of the specialist sector. There are also several newer groups, such as Women for Sobriety and Drink Watchers (see Appendix C), that offer an alternative ideology and model of recovery. Although these groups are used by some persons, but do not yet have the acceptance or the worldwide distribution currently enjoyed by AA (J. Kirkpatrick, Women for Sobriety, personal communication, December 14, 1987~. AA was founded in 1935 by Bill W., a New York stockbroker, and Dr. Bob, an Akron surgeon, who met at Bill W.'s initiative to discuss their problems in abstaining from drinking alcoholic beverages (Alcoholics Anonymous World Services, Inc., 1955, 1959~. (Consistent with AA's tradition of anonymity, the literature does not use last names, although Bill W. had participated quite publicly in the expansion of research, teaching efforts, and treatment services. He testified before Congress in 1970 at the hearings held by Senator Hughes regarding the need to develop a cohesive national policy and to establish the National Institute on Alcohol Abuse and Alcoholism.) Al-Anon is a network of similar self-help groups for the spouses of persons with alcohol problems; Alateen serves the same function for their children (Ablon, 1982; Al-Anon, 1986; Cermak, 1989~. AA has grown to be a worldwide organization while still maintaining its basic structure and traditions (Leach and Norris, 1977; Kurtz, 1979; Alibrandi, 1982; Rudy, 1986~. Indeed, the use of AA principles and techniques has become an integral part of the majority of treatment programs in this country (Boscarino, 1980; Bradley, 1988~. AA is the best-known alcohol problems treatment resource. and most lav~ersons consider it to he the most useful (Robinson and Henrv. 19791. Antabuse, alcohol education, group counseling). _, ~ ~ . . , . < - ~, ~O ~1 - - , ~ ~ Belonging to AA demands participation in a program of recovery, called by the organization "working the twelve steps." The twelve steps are guides to the process of personal chance that is required to achieve sobriety. A program of recovery includes (a) paruc~pa~ng In meetings in which members share the history of their problems caused by drinking and their experiences in maintaining sobriety; (b) obtaining help and support from other members in meeting the challenges that in the past have led to "slips" and a return to drinking; and (c) finding an AA member who will serve as a sponsor and provide guidance and help in times of crisis when the urge to return to drinking becomes overwhelming. Members typically attend at least one meeting a week; new members are encouraged to attend daily meetings Ninety meetings in 90 daysn). The AA program of recovery and Its pn~osopny are described In a number of publications that are studied by all members. The fundamental text is the book Alcoholics Anonymous, published by AA's General Services Office (Jackson, 1988~. From AA's inception, its members have viewed their problems with alcohol as "alcoholism-an illness that prevents those afflicted with it from controlling their drinking. In the organization's view "recovery" requires self-diagnosis and acceptance of the inability to control drinking and its inevitable consequences: therefore. according ~o AA recovery requires abstinence. The individual AA group and the meetings it holds are of central importance to the organization's functioning. Meetings have a common structure: one member is elected _ ~, O I- ) ~1 ~ 7 ~-- ~_ _ _ an, I,,,
WHO PROVIDES TREATMENT? 109 as chair for the meeting, and one or two members tell their stories-an account of their personal history, the development of drinking problems, the sufferings experienced and inflicted on others, the deceptions and lies, and finally "hitting bottoms and beginning to turn around. A description of their introduction to AA and the process of recovery within the ~fellowship," with practical hints on "working the steps, completes the presentations. Although structured, the meetings are informal and friendly; the focus is on the sharing and common recognition of the problems that are faced by all who attend and participate in the discussion. Reference is frequently made to the 12 steps and to the meaning a given step has for a member and the effort that was required to achieve that step. In addition to meetings there may be study groups and social gatherings held informally or at a central meeting place. At such events, AA literature will be discussed and passed around. As they develop, local groups become recognized and listed in the directories published by the local or central AA service office. Often, groups work together to form a local central office or intergroup association; there, volunteers will answer phone requests for information and serve on committees. There are also area and national conventions at which members meet to discuss the organization and To continue to carry on the traditions of the fellowship." The more experienced AA members engage in Twelfth-stepping-serving as sponsors and working with new members to engage them in the recovery process. More experienced AA members may also serve on institution committees that arrange for meetings to be held in treatment facilities, make AA literature available to persons in treatment there, and arrange sponsorship for those in treatment. The members may volunteer to conduct the meetings at the institutions and to run orientation and study sessions. In 1987, AA membership was estimated to be more than 1.5 million persons in more than 73,000 groups worldwide (Trice and Staudemeier, 1989~. Membership in the United States and Canada was estimated by the AA General Services Conference to be about 800,000 affiliates. In the United States the largest numbers of members are to be found in California (18 percent of active members), New York (6 percent of active members), Illinois (5 percent), and Texas and Minnesota (4 percent each) (Jackson, 1988~. The AA General Services Office conducts a survey of a sample of its membership every three years (Alcoholics Anonymous World Services, Inc., 1987~. The most recent survey of 7,000 U.S. and Canadian affiliates was conducted in 1986. The survey found that men constituted the majority of members (66 percent), although the percentage of women had continued to increase from 30 percent in 1980 and 1983 to 34 percent in 1986. The majority of members continued to be in the 31-to-50 age bracket; the trend toward adding younger members, which was noted in earlier surveys, appeared to have leveled off (those in the 30-and-under age range constituted 21 percent in 1986 after an increase from 15 to 20 percent between 1980 and 1983~. Sixty percent reported prior counseling. The average member attended four meetings per week. The average length of sobriety for members was 52 months, with 29 percent reporting sobriety for more than five years, 33 percent reporting sobriety for one to five years, and 33 percent reporting sobriety for less than one year. The upward trend of member drug problems in addition to alcohol problems continued, with an increase from 31 percent in 1983 to 38 percent in 1986. AA does not see itself as serving those with only or primarily drug problems. To assist those persons, AA has offered assistance to other self-help groups modeled after AA that target persons with drug problems (Alcoholics Anonymous World Services, Inc., 1988~. AA can function in a number of ways for a person experiencing alcohol problems: as the main resource used for recovery, as part of a formal treatment plan, or as an aid in sustaining the recovery achieved through formal treatment (Diesenhaus, 1982; Hoffmann et al., 1987; USDHHS, 1987; Bradley, 1988; Anderson and Gilbert, 1989~. A large number of persons with alcohol problems recover using AA alone or in conjunction with
110 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS professional treatment, although the precise number of such individuals is not known with certainty (USDHHS, 1987~. There is evidence that continuing attendance at AA meetings is positively correlated with the maintenance of abstinence, although it is not clear whether it is the attendance itself or the motivational factors leading to continued attendance that are the determining factors (Emrick, 1987~. Although AA does not view itself as a treatment modality (e.g., Jackson, 1988), it has been viewed as such for evaluation and planning purposes because of the prominent role it plays in the design and implementation of treatment programs in this country. There are two discrete elements to this role. The first aspect is the formal relationships that exist between the intergroup or local AA committees and treatment facilities or other institutions (e.g., prisons, jails). Procedures have been developed that allow AA volunteers who are doing "twelfth-step" work to serve on the institutional committees that arrange for meetings and sponsors. Experienced AA members may also visit the facility regularly to run an open meeting, develop and support an institutional group that is listed with the AA General Services Office, or meet potential affiliates seeking sponsors (Alcoholics Anonymous World Services, Inc., 1961, 1979~. Continuation in AA after discharge from the institution is stressed; AA serves as the major aftercare mechanism for many primary treatment programs. The second aspect of the AA role is the use of its philosophy, methods, and materials by professional and recovered staff in carrying out formal treatment programs (Laundergan, 1982; Nace, 1987; Weisner and Room, 1984; Bradley, 1988; Gallant, 1988~. Many programs blend professional diagnostic and treatment activities with the 12-step AA recovery program, and there is strong emphasis on the use of "recovering alcoholics" as primary counselors to guide the person in treatment through a multidisciplinary program. For example, many treatment programs center their education and counseling around AA-approved publications, in particular, the "Big Book," requiring that it be read and discussed in group sessions. Many programs also use workbooks (e.g. the Hazelden Foundation's "Guide to the Fourth Step Inventory" and other similar publications) to guide the nstepwork" carried out in group and individual sessions. Treatment programs often hold AA orientation sessions and meetings at the treatment facility, which persons in treatment are encouraged or required to attend. Persons in treatment are also encouraged to find an AA sponsor prior to discharge, and continued involvement in AA is a major component of many facilities' aftercare planning. Programs that adhere to the Minnesota model often establish criteria for the completion of a treatment stage in terms of stepwork (e.g., discharge from primary rehabilitation in concert with taking the AA "Fifth Steps [Laundergan, 1982~. AA as an organization does not consider itself to be a formal treatment program, but there are many individuals who use only AA, initially or after a relapse or slip, to recover. Affiliating with AA involves the same stages of treatment as a formal treatment program. Each stage can be carried out in either type of program, with movement back and forth, or conjointly, following the orientation of the Minnesota model and the California social model programs. Subacute detoxification can be and often is carried out at home with support, encouragement, and monitoring of physical status by other AA members. Primary rehabilitation coincides with Working the steps," just as in formal programs with an AA orientation. Continuing to attend meetings and working the program with a sponsor's guidance are equivalent to formal extended care and maintenance or relapse prevention. A person may use various techniques for relapse prevention. Increasing the number of meetings he or she attends, increasing study of the Wig Books and other AA materials, and seeking more direct support from a sponsor and other AA members. Lifelong maintenance, or aftercare, is available by continuing to attend meetings, doing "twelfth-step work, and volunteering for group and intergroup responsibilities. This reformulation of the AA program of recovery in the terms of the committee's classifying
WHO PROVIDES TREATMENT? scheme does not attempt, as others have done (e.g. Khantzian and Mack, 1989), to analyze and explain how AA functions (based on a psychological or sociocultural theory). Rather, the committee wishes to present AA within the same framework as formal treatment to suggest the possibility of studying who can and should be matched with the AA program, either as the person's sole treatment modality or in conjunction with other treatments. AA is considered by many lay persons and professionals to be the most successful treatment for persons with alcohol problems (Bradley, 1988), despite the lack of well-designed and well-executed studies that can be cited to support or negate the validity of this perception (Ogborne and Glaser, 1981; Glaser and Ogborne, 1982; Emrick, 1989b; Ogborne, 1989; Trice and Staudemier, 1989~. Research has shown that not all who are introduced to AA, either as a component of a formal treatment program or as an alternative to formal treatment, affiliate with the organization and that not all who affiliate, benefit (Emrick, 1989a,b; Ogborne, 1989; Trice and Staudemier, 1989~. It has been estimated that only 20 percent of persons with alcohol problems who are referred to AA ever attend meetings regularly. Additional research is needed to determine the characteristics of those who will affiliate and benefit so that matching criteria can be developed. Guidelines for such research have been suggested by Ogborne and Glaser (1981~. Like AA, drinking-driver (DWI) programs and employee assistance programs (EAPs) represent significant forces in the development and structuring of the specialist alcohol problems treatment sector (Weisner and Room, 1984~. Although these programs are primarily thought of as referral and intervention programs, they can be said to provide treatment services as the committee defined treatment for alcohol problems in Chapter 3. Drirlking-driver programs Although the name may differ from state to state, DWI programs are specialty referral and treatment programs for drinking-and-driving offenders. In each state a network of specialized programs provides intervention and treatment services to persons who have been arrested for or convicted of an alcohol-related traffic offense. These programs now include a differentiation into first-offender and multiple-offender programs (California State Department of Alcohol and Drug Programs, 1988; McCarthy and Argeriou, 1988~. Most admissions to such treatment are referred by the courts, either through a diversion program or as part of a sentencing arrangement, and these specialty programs must meet specific standards to qualify for receiving court referrals. The licensing arrangements vary from state to state and often involve the state alcoholism authority as well as agencies involved in public safety, highway safety, or the court and corrections (probation) systems. DWI programs are considered by some to be more a part of the corrections sector than the alcohol problems treatment sector (Weisner, 1986~; these programs are discussed in more detail in Chapter 16 and Appendix D. Employee assistarwe programs Employee assistance programs, or EAPs, are included in the specialty sector although they no longer deal exclusively with alcohol problems. Instead, most such programs have adopted a "broad-brush" philosophy that encompasses other personal problems that may be affecting job performance (Roman, 1981~. Today, EAPs can be thought of as agencies that provide identification, intervention, diagnostic services, referral, and follow-up services to persons at their place of employment. In addition, EAPs provide primary prevention services to all employees and consult with supervisors and managers on ways to work with troubled employees. Increasingly, EAPs are also providing short-term outpatient counseling services as primary treatment (Sonnestuhl and Trice, 1986~. EAPs may be internal, with services administered and provided by employees of the sponsoring company or government agency, or external, with services provided by an independent contractor. EAPs generally are not classified as treatment programs but as prevention and intervention programs (USDHHS, 1987b). However, EAPs offer a variety of services, ranging from short-term counseling (intervention, primary rehabilitation) through day care
112 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS (primary rehabilitation) to worksite aftercare groups (maintenance) (Roman and Blum, 1985; Sonnestuhl and Trice, 1986) and consequently, they are considered by some to be treatment providers. A recent survey of services offered by EAPs found that 74 percent of the 1,238 respondents provided "brief in-program counselings and 10 percent provided In-program treatments (e.g., a "company run residential programs) (Backer and O'Hara, 1988~. More than 94 percent of the respondents reported that their EAPs also offered crisis intervention services. Although this survey focused on drug abuse services, given the approach used by most EAPs and the history of their development, it can be assumed that at least as many EAPs offer these treatment services for persons with alcohol problems. EAPs are the outgrowth of the industrial alcoholism movement initiated in the 1940s (Roman, 1981; Trice and Schronbrun, 1981) and were originally established to deal exclusively with persons with alcohol problems. Although there are several historical antecedents to the development of work site programs to detect and refer employees whose job performance is negatively affected by their excess drinking, the explanation cited most often for the successful initiation of programs is the coalition of efforts between industrial physicians and recovered alcoholics who sought to bring AA principles to their coworkers (Roman, 1981; Trice and Schonbrun, 1981; Delaney, 1988~. Other contributions included the efforts of the Yale Center for Alcohol Studies during the 1950s, of the National Council on Alcoholism's industrial services' program during the 1960s, and of the private Smither's Foundation. All three organizations obtained information on the programs operating in various companies and diffused that information to other executives and physicians. Joint efforts to develop programs cosponsored by unions and management were strengthened by the interest and involvement of the AFL-CIO community services program and the United Auto Workers. EAPs have been important contributors to the development of the contemporary specialist alcohol problems treatment sector. When NIAAA was established in 1971, it adopted as one of its major priorities the identification and referral to treatment of employed persons with alcohol problems. Emphasis was placed on early intervention and identification by way of impaired job performance. A major goal during the 1970s was the development of treatment resources, both programmatic and financial, for the employed person with alcohol problems. Corporations and government agencies were encouraged to develop both EAPs and specific health insurance benefits for treating alcohol problems. The availability of third-party funding and referrals from EAPs, which shared the ideology underlying the Minnesota model of treatment, were major determinants of the nationwide spread of programs to treat persons with alcohol problems (Roman, 1982~. A State Perspective on Treatment Pronders Given this complex array of sectors and providers, it is understandable that individuals who are seeking help for their own alcohol problems or for someone they care about may have some difficulty identifying the program or person who would best be able to assist them. Each state and each community have developed their own formal and informal "mapping" of the treatment system and of individual providers, as well as their strengths and weaknesses. Many publish directories to guide persons seeking a referral, whether as a professional, a family member, or a candidate for treatment themselves. To better understand who provides which services and for whom, it is helpful to review the treatment system as described in one of the states, at the same time recognizing that there is some variation in the continuum of care among the states. As described earlier (see Chapter 3), Minnesota has been considered a leader in the development of treatment services to persons with alcohol problems and uses a formulation of a continuum of care that includes stages and equivalent, alternate settings.
WHO PROVIDES TREATMENT? TABLE 4-1 Overview of the Current Continuum of Care for Minnesota Residents ~3 Prevention/Inte~vention Services Treatment Seances Prevention and education programs Information, diagonstic, and referral programs County social services agencies Mental health centers Other information and referral programs Self-help programs Employee assistance programs (EAPs) Dnving while intoxicated clinics Detoxification centers Primary residential treatment programs Freestanding facilities Hospital-based Facilities State regional treatment centers Intermediate/Extended residential treatment programs Halfway houses Extended care facilities Board and lodging facilities Nonresidential treatment programs Freestanding facilities Hospital-based facilities SOURCE: Directory of Chemical Dependency Programs (Minnesota Chemical Dependency Program Division, 1987). Several of the models reviewed in Chapter 3, including the model used as the basis for recommendations in the recent national plan (USDHHS, 1986), were derived from the Minnesota continuum of care. Because the committee has used developments in Minnesota elsewhere in the report as examples of trends, it seems consistent to use a description of the different kinds of programs available in Minnesota to portray the variety of treatment providers available across the country. The programs listed are drawn from each of the general and specialist sectors discussed in the first part of this chapter and illustrate the increasing diversity in programs and funding sources that must be captured in national surveys if the evolving nde facto alcohol problems treatment system" is to be understood. Table 4-1 provides an overview of the current continuum of care available to Minnesota residents. Each of the categories of intervention and treatment programs described in the directory are discussed below; the program descriptions are summaries of those in the directory. Information, diagnostic, and referral programs These programs provide assessments of chemical use related problems for individuals, families, and concerned persons and refer them for appropriate treatment services. There are 196 information, diagnostic, and referral centers listed in the Directory. The majority (86) are operated by county social services agencies; mental health centers operate the next largest group (32~. A variety of other agencies (public health departments, family and human services agencies, alcohol and drug counseling agencies, hospitals, nursing homes, community action agencies, senior citizens programs, community centers, etc.) operate the remainder. Each county social service agency provides these services; some county social service agencies also offer direct treatment services. Many of the mental health centers and other information and referral programs also provide treatment services. Self-help programs fall under this category and provide a range of services from information through aftercare. There are 11 self-help program offices listed in the Minnesota directory, including 2 AA intergroup offices; the others include Al-Anon,
114 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Women for Sobriety, Narcotics Anonymous, and the Indian Health Board. The directory notes that there is no charge for the services of these groups. The directory describes EAPs as programs that provide identification, intervention, diagnosis, referral, and, in some instances, direct counseling to persons at their place of employment. The directory notes that EAPs can be internal, operated by the work organization itself, or external, operated by a specialist under contract. Not all known EAPs are included; the directory lists only three of the major EAPs operated by companies or government agencies for their own employees and 15 consulting organizations that offer EAP services to companies and institutions. Driving while intoxicated clinics-These programs provide education for those individuals who are arrested, convicted, and referred by the court system for alcohol-related traffic offenses in an attempt to motivate the drinking driver to alter his drinking-and-driving behavior. Minnesota's DWI clinics are specialty programs authorized by the state's Department of Public Safety to provide a defined course of education on the effects of alcohol on driving for individuals referred by the court system as the sentence or a part of the sentence following conviction for an alcohol-related driving offense. The course length must be no less than eight hours and no more than nine hours, usually divided into three or four different class sessions; the state specifies curricula and provides instructional presentation guidelines. DWI clinics are required to be nonprofit and must be part of a sponsoring organization such as a mental health center or a safety organization. They are supported by registration fees paid by the students. The persons served tend to be residents of the county of the court's jurisdiction because as part of the sentence there are geographic restrictions on the distance that can be traveled (no more than 35 miles from the student's residence). Detoxification centers-These programs provide subacute detoxification with minimal medical services provided onsite. Three categories of service are provided: (1) health observation during acute intoxication and withdrawal to ensure medically safe detoxification; (2) basic personal care, including provision of meals, clean clothing, and protection of the person and the person's belongings; and (3) assessment of the person's relation to chemicals and of his or her other problems, determination of service needs, and referral to appropriate community resources. Minnesota decriminalized public intoxication in 1971 and mandated the establishment of detoxification centers by the counties. In 1987 there were a total of 37 freestanding and hospital-based subacute detoxification centers operating across the state, ranging in size from 1 to 88 beds. Typically, these subacute medical model centers have a consulting relationship with a physician, and there is at least one licensed nurse on the staff. Detoxification technicians who are trained onsite provide the majority of direct services. Larger centers have counseling components; smaller centers use counselors from the county chemical dependency program or elsewhere for this purpose. Larger centers usually have nurses on staff for all shifts and a physician who comes into the facility on a regular basis; smaller centers typically have a nurse on duty during the day and one on call for emergencies during off hours. Length of stay varies from 1 to 7 days, although one center offers care for as long as 21 days. The average length of stay is 2 to 4 days. There are 18 freestanding and 16 hospital-based detoxification centers; there are two detoxification centers that are part of a community mental health center and one located in a correctional facility. Charges range from $80 to $198 per day. One of the six
WHO PROVIDES TREATMENT? 115 state hospitals (regional centers) also reports offering detoxification. The charge is given as $101 per day. Sources of funding vary among the centers; they include county government, state government, Medicare, Medicaid, private health insurance, client fees, private donations, Title XX (the social services block grant), county social service funds, state Medical Assistance, local government, and public welfare. Other characteristics of the centers surveyed that are noted in the directory are services provided, security (e.g., seclusion room), and patterns of medication use. Freestanding primary residential treatment These programs provide intensive rehabilitative services (medical and psychological therapies) within a highly structured therapeutic living environment. Their efforts are aimed at helping individuals modify their behaviors related to chemical use and to develop the personal and social skills necessary to successfully reenter the community. Minnesota's 24 licensed, freestanding primary residential treatment programs range in size from 13 to 197 beds. Charges range from $80 to $295 per day. Reported funding sources include fees, private health insurance, county funds, food stamps, state grants-in-aid, Title XX, United Way, the Indian Health Service, private foundations, and individual donors. Eleven programs report that they also provide detoxification services. Six programs describe their target populations as adolescents who most often range in age from 12 to 18 years; 14 other facilities admit youth (under the age of 18) to their adult programs. There are two programs that report American Indians as their target population. All programs admit both men and women; there is one program that serves adult gay men and lesbian women. Hospital-based primary residential treatment programs_These programs provide intensive rehabilitative services (medical and psychological therapies) within a highly structured therapeutic living environment. Like the freestanding facilities, their aim is to help individuals modify those of their behaviors that are related to chemical use and to develop the personal and social skills necessary to successfully reenter the community. There are 29 hospital-based primary treatment programs in Minnesota ranging in size from 10 to 97 beds. Iwo of the programs are in Veterans Administration hospitals, and one is in a university hospital. Charges range from $121 to $306 per day. Planned length of stay varies from 14 to 72 days for the 24 programs reporting a fixed-length program. Five programs describe their length of stay as variable or determined by the person's need. Six programs target adolescents and 10 others admit youth under the age of 18. A1129 programs report admitting both men and women. The regional treatment centers are state hospital-based programs that provide a range of intensive rehabilitative services within a structured living environment. Their aim is to help individuals modify those of their behaviors that are related to chemical use and to develop the personal and social skills necessary to reenter the community successfully. The six state hospitals (regional centers) also report offering primary residential treatment. The charge given is $101 per day. The programs vary in their length of stay, orientation, and profile of services offered. One also offers detoxification, and another offers extended care. Halfway houses-These transitional living facilities provide a supportive environment and rehabilitative services for persons who have completed
6 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS primary treatment but who are not completely prepared to reenter the community without additional help. There are 39 halfway houses listed in the 1987-1988 Minnesota Directory of Chemical Depended Programs; 17 programs serve only men, whereas 4 admit only women. The facilities vary in size from 10 to 60 beds. Age limits vary considerably: 3 halfway houses specialize in working with adolescents, 1 specializes in helping young adults, and 17 of the 36 adult facilities also admit youth under the age of 18. Six halfway houses are targeted at American Indians, and one is targeted at adult black Americans. Six report that they receive contract funding from the Veterans Administration. One of the facilities serves parolees and probationers. There are two facilities that report serving chemically dependent mentally ill individuals (commonly known as Dual-diagnosis patientsn). Charges for halfway house stays in Minnesota range from $8 to $70 per day. The sources of funding listed in the directory include food stamps, county funds, the Indian Health Service, state appropriations, private health insurance, Title XX, and general assistance funds. Extended care facilities These programs provide long term residential treatment services within a structured living environment to severely chemically dependent individuals who have had prior treatment experiences. The directory lists 12 extended care facilities. Ho programs report that they serve only men, and two admit only women. The facilities vary in size from 10 to 60 beds. Age limits vary considerably with two facilities specializing in work with adolescents; one of the 11 adult facilities also admits youth under the age of 18. One facility is targeted at male veterans, another is targeted at men and women over the age of 55, and another specializes in work with chemically dependent mentally ill individuals. The charges listed range from $31 to $125 per day. Sources of funding include food stamps, county funds, the Indian Health Service, state appropriations, private health insurance, Title XX, general assistance, client fees, Medicare, Medicaid, private donations, and child welfare funds. Board and lodging programs These programs serve the needs of the chronic alcoholic who is essentially homeless and indigent and has failed to maintain sobriety despite prior treatment; the purpose of the program is to provide humane care, basically food and shelter, within a warm safe environment that involves some personal responsibility and communal activities with the intent of improving the individual both physically and socially. There are 20 board and lodging facilities listed in the Minnesota directory. (In the stage model of treatment suggested by the committee, these would be considered as maintenance facilities.) The facilities vary in size from 8 to 200 beds (at a Salvation Army adult rehabilitation center). The length of stay varies, with 10 facilities having no restrictions; others set limits of six months to one year. Admission requirements also vary. considerably, with four facilities specializing in working with men and two with older adults; one facility is located within a nursing home. The charges listed range from no fee (a Salvation Army program) to $600 per month. Sources of funding include Supplemental Security Income, (SSI), United Way, county funds, the Veterans Administration, state appropriations, private health insurance, Title XX, Medicare, Medicaid, client fees, private donations, and general assistance.
WHO PROVIDES TREATMENT? Freestanding nonresidential treatment programs-These programs provide a range of rehabilitative services to less severely dependent individuals who are able to modify those of their behaviors that relate to chemical use while still functioning in the community. ~7 There are 105 freestanding nonresidential treatment programs offering a wide range of programs: f~xed-length, structured primary and extended care rehabilitation programs at a feed cost ranging from $275 to $3,500, as well as more traditional outpatient psychotherapy with weekly sessions for a feed or variable length of stay. The charges per session in this category range from $25 to $75. Funding sources vary considerably but include all those available to the residential programs. Hospital-based nonresidential programs These programs provide a range of intensive rehabilitative services to less severely dependent individuals who are able to modify those of their behaviors that relate to chemical use while they continue to function in the community. There are 55 hospital-based, nonresidential treatment programs offering a wide range of programs: fed-length, structured primary and extended care rehabilitation programs at a fixed cost ranging from no charge (Veterans Administration) through $900 to $1,850, as well as more traditional outpatient psychotherapy with weekly sessions for a fixed or variable length of stay with charges per individual session ranging from $38 to $85. Funding sources vary among the individual programs but include all those available to the residential programs. Both freestanding and hospital-based nonresidential programs offer day and evening sessions, dividing their treatment episodes into phases; the most common division is a primary care phase followed by an aftercare phase. Some offer several programs with alternative durations and intensities (frequency and length of sessions). Various designators are used to describe the program and its phases. Lengths of stay for each phase and for the total treatment episode, hours of contact, and number of sessions per week differ. Most facilities identify their program as an intensive primary care program lasting about 5 weeks with four sessions per week followed by aftercare lasting 12 weeks with one session per week. Almost all structured programs include a family component (e.g., 5 weeks, two sessions per week while the person in treatment attends four sessions per week). In terms of special populations (see Section IV), Minnesota reports that 30 of its programs provide specialized services to American Indians, 3 programs serve blacks and 3 serve Hispanic Americans. There are 16 halfway house programs that serve men only and 53 programs that provide specialized services to women. There are 66 programs that indicate the availability of special services to youth; 13 programs report offering specialized services to the elderly. There are 60 programs serving those with "dual disabilities mental illness and chemical dependency. A Federal Perspective Like the Minnesota and other state alcoholism authorities, the federal government is primarily a funder and regulator of treatment for alcohol problems. Yet the federal government also operates a number of very large, nationally dispersed intervention and treatment systems that share the diversity seen in the states. Similarly to the states, federal agencies operate or contract for EAPs to serve their employees under Office of Personnel Management guidance. There are also drinking-driver programs for military personnel, and there are treatment programs provided for selected employees and beneficiaries.
8 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Through its Department of Medicine and Surgery, the Department of Veterans Affairs, previously known as the Veterans Administration (VA), operates the largest centrally directed health care system in the nation. The VA provides treatment for alcohol-related problems/disorders to all eligible veterans (VA, 1977; Macro Systems, Inc., 1980; NIAAA, 1983b). VA investigators also conduct alcohol-related basic, clinical, and services research (IOM, 1989~. Treatment and rehabilitation for alcohol dependence first began in VA hospitals in 1957; in 1967 the VA established an office to operate alcohol and drug abuse treatment as special medical programs within its psychiatric services. The first separately funded alcohol dependence treatment units (ADTPs) were established in 1970. All VA hospitals have the capability to treat alcohol-related medical emergencies, either in a specialized unit or on the medical service. By fiscal year 1986 the VA's 172 hospitals were operating 103 specialized ADTPs along with 51 drug dependence treatment programs (DDTPs). During that year the specialized ADTPs treated more than 53,000 inpatients; more than 44,000 veterans with alcohol problems were treated in psychiatric units or medical beds (VA, 1987~. The average length of stay in the ADTPs was 21.1 days. The average length of stay of all those discharged with a principle diagnosis of alcohol dependence or alcohol abuse was 16.3 days. The occupancy rate for the approximately 3,600 specialized ADTP beds was 85.1 percent. When both the principal and associated diagnoses are considered, alcohol-related disorders (22 percent) are second only to heart disease (41 percent) as the most common diagnoses among patients discharged from VA hospitals. This finding suggests that approximately $2 billion of the VA's total health care budget of more than $9.5 billion constitute expenditures to deal with alcohol problems. During fiscal year 1980 the VA was given the authority to contract with non-VA community programs for treatment and rehabilitation services for veterans with alcohol or drug dependence or abuse disabilities. Between fiscal years 1984 and 1986 the VA inpatient programs used this authority to place approximately 5,000 veterans in halfway houses for 60 to 90 days of extended care. The VA has introduced a prospective payment methodology (see Chapter 18) to fund its hospitals and outpatient clinics; the alcohol and drug abuse treatment services are also included in this method of financing (Errera et al., 1985; Nightingale, 1986~. There have been no studies to date, however, of the impact of the introduction of this new financing mechanism on the functioning of the ADTP or on the outcome of treatment for alcohol problems. The Department of Defense (DOD) provides prevention and treatment and rehabilitation services for both its civilian and military work forces, as required by law. The assistant secretary of defense for health affairs is responsible for developing policy. DOD has developed a comprehensive public health approach to the control of alcohol and drug use that utilizes education, law enforcement, and treatment. Each of the military services and the Defense Department agencies manages its own program within the policy guidelines promulgated by the assistant secretary. The treatment programs vary among the services, but all stress education, detection, and rehabilitation (Orvis et al., 1981~. Alcohol is considered to be the primary substance abuse problem. Both hospital-based and residential programs are used for those who are judged to be more severely impaired. The overall orientation of the DOD programs reflects a mixed medical-social model; AA concepts are integrated into the program philosophies. The department conducts periodic surveys to aid the evaluation of the effectiveness of its policies and to monitor the prevalence of alcohol and other drug problems. Urine testing is also conducted and is believed to deter abuse (Bray et al., 1985~. The Bureau of Prisons provides treatment for alcohol problems to inmates of federal penal institutions and makes arrangements for those who achieve community status (i.e., probation, parole, residing in a community center) to receive appropriate treatment
WHO PROVIDES TREATMENT? 119 or aftercare services. There is no centralized, formally organized alcohol problems treatment program administration; each institution designs and evaluates its own program. Similarly, there is no formally structured diversion or treatment program for detainees in the pretrial phase or for parolees in the community; individual placements are made, and community corrections facilities are required to provide a minimal level of aftercare. Combined chemical abuse treatment units housing inmates with both alcohol and drug problems constitute the majority of the programs within the institutions. AA meetings, coordinated by volunteers from the community, are a major component of these institutional programs. The Indian Health Service (IHS), through its Office of Alcoholism, sponsored the operation of 309 alcohol problems treatment programs in fiscal year 1987 (IHS, 1988; Rhoades et al., 1988~. Alcohol problems treatment is also provided in IHS hospitals and primary care clinics. The IHS Office of Alcoholism was established in 1978 as a result of the passage of Public Law 94-437 and was given the responsibility to administer the American Indian/Native American alcohol treatment programs that had originally been funded through the Office of Economic Opportunity and the NIAAA categorical grants (see Chapters 15 and 18~. The agency has developed its own stages of treatment model, focusing its rehabilitation efforts on nonhospital alternatives. Detoxification is primarily the responsibility of the IHS nonspecialist health components. Treatment (rehabilitation), which is provided by contract agencies following IHS guidelines and specifications, is provided in three environments: primary residential, halfway house, and outpatient. IHS conceptualizes these three environments as components along a continuum of care. The ideal course of treatment is one in which one of the 42 primary residential treatment centers (PRTCs) serves as the entry point for persons who need Intensive counseling and education along with a very structured environment that is free of alcohol and other drugs. On successful completion of the first phase of rehabilitation in the PRTC, the patient moves on to the next stage of treatment in an outpatient counseling program or halfway house in his or her own community, either for continuing treatment or aftercare. Halfway house continuing treatment is for those patients who complete the primary residential treatment phase and require additional time in a drug-free structured environment as well as follow-up counseling. Outpatient continuing treatment is for those patients who are returning to a family and community environment that is supportive of recovery. Outpatient treatment is also used as an alternative to inpatient (primary residential) treatment when a bed is not available or when the family and community will support the initial phase of primary treatment on an outpatient basis. Outpatient treatment is sometimes used as a stopgap measure while waiting for a PRTC or halfway house bed to become available. cat A National Perspective Another means of understanding the structure of the alcohol problems treatment system throughout the nation is by reviewing the data from national surveys. Since the early 1970s there has been an ongoing effort to provide state and federal policymakers with the information they require to manage the resources needed to provide treatment services for persons with alcohol problems. As a major part of this effort the National Institute on Drug Abuse (NIDA) and NIAAA have periodically conducted surveys of all known public and private treatment facilities, seeking data on such variables as capacity, staffing, funding, utilization, and services. Since 1979 this survey, which was originally known as the National Drug and Alcoholism Treatment Utilization Survey (NDATUS), has been conducted jointly by the two institutes and therefore contains responses from units that provide services only for persons with alcohol problems, as well as from units
120 BROADENING TEIE BASE OF TREATMENT FOR ALCOHOL PROBLEMS that provide treatment for persons with both alcohol and other drug problems (NIAAAa, 1983; Yahr, 1988~. Now known as the National Drug and Alcoholism Treatment Unit Survey, the NDATUS is a survey of specialist facilities and programs that provide an organized program of alcohol and drug abuse services. The NDATUS was originally conducted in 1974 by NIDA In 1979, however, it was expanded to include alcoholism as well as drug abuse facilities. The 1984 survey, renamed the National Alcoholism and Drug Abuse Program Inventory (NDAPI), did not obtain the same information as previous NDATUS efforts; in fact, the amount of information collected from each reporting unit by the NDAPI was greatly reduced from that collected in earlier years. This reduction in collected data was part of the overall effort by Congress and the Reagan administration to streamline grant program management and reduce federal reporting requirements. These modifications were introduced with the advent of the alcohol, drug abuse and mental health services block grant in 1982 (Institute for Health and Aging, 1986~. Unlike the 1984 survey, the 1987 survey contained questions to solicit additional information that was seen by both federal and state policymakers as necessary to study the distribution of services (USDHHS, 1986~. The survey was designed to meet several objectives: (a) the development of an updated listing of substance abuse units for an information and referral hotline operated by NIDA; (b) the provision of information to policymakers about the type of services provided by treatment units, their capacity and utilization, and their funding sources and levels; (c) the collection of aggregate data on selected characteristics of persons using the services (age, sex, and race). The 1987 NDATUS attempted to survey all known facilities and organized programs that provided any services to persons with alcohol and other drug-related problems. A treatment unit was defined as a facility that had (a) a formal structured arrangement for drug abuse or alcoholism treatment using specified personnel; (b) a designated portion of the facility (or its resources) set aside for treatment services; (c) an allocated budget for such treatment; and (d) treatment services provided directly at the facility. The NDATUS also provided a point prevalence survey of utilization (i.e., the number of persons enrolled in formal treatment on October 30, 1987, the date of the survey). A unit was not included in the analysis if it did not provide some information on persons actually in treatment. As a result, there is a substantial amount of missing data and the committee has not been able to use the data as extensively as it had originally planned. In the 1987 NDATUS, in contrast to previous surveys, programs with satellite units were given the option of reporting at either the program or unit level. Therefore, the information that were collected represents an unknown mix of program and unit data (NIDA~IAAA, 1989~. The 1987 NDATUS also obtained basic information for the NIDA hotline listing from prevention and other nontreatment units. Some of these units appear to provide intervention and assessment services that would be included in the broader definition of treatment being used by the committee. Although the 1987 NDATUS was expanded because the 1984 NDAPI did not provide sufficient information about the scope and characteristics of the treatment delivery system, the revised survey still does not contain all of the information obtained in prior years. The most notable missing information is staffing patterns. The format and level of detail contained in these surveys have varied over the years, although an effort has been made to utilize common response categories and definitions whenever possible to enable comparisons with data collected in previous years and to describe trends. Because there have been differences in definitions, however, as well as in response rates among the states and between years, comparisons among them can only be seen as tentative and exploratory (Reed and Sanchez, 1986~. Therefore, trend analysis has not been undertaken, and the NDATUS is used primarily to describe the
WHO PROVIDES TREATMENT? 121 current situation. Trend analysis is important in understanding the changes in treatment availability and should be undertaken in more comprehensive studies directed at the evolution of the specialty alcohol problems treatment sector. NL4A'4 should develop an ongoing program for analysis of the NDATUS data, incllldingana~ses of carefulb designed subsets of programs that have KSpOtlded to the survey over the years. A total of 8,690 programs and units responded to the 1987 NDATUS (NIDAINIAAA, 1989~. The majority (6,866) described their functions as including treatment; 5,211 units described their functions as including prevention and education, and 3,844 units indicated other functions. There were 5,791 treatment units that reported providing treatment services to persons with alcohol problems, 1,708 (29 percent) of them described their orientation as providing alcoholism services, and 4,083 (71 percent) identified their orientation as combined alcoholism and drug services. There were 337,337 persons receiving services on the census date (October 30~; with budgeted capacity at 416,337 in the 5,627 units that reported on their active patients, the utilization rate was 81 percent. TABLE 4-2 Location of Units Providing Treatment to Persons with Alcohol Problems Units Persons in Treatment October 30, 1987 Unit's LocationNumber ~Number% Community mental health center8421460,94617 Hospitala1,1662055,27016 Correctional facility6012,9451 Halfway house/recove~y home6981212,8384 Other residential facility7011221,7056 Outpatient facility2,00435173,91250 Other319622,9736 Not reporting1c24c Total5,791100350,613100 SOURCE: NIDA/NIAAA (1989:Table 7). aIncludes general hospitals, VA hospitals, alcoholism hospitals, mental/psychiatric hospitals, and other specialized hospitals. belie recovery home classification was added to meet concerns expressed by providers who utilize the California social model of recovery. CLess than one percent.
22 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS According to this survey, the majority of persons in treatment (61 percent) is now being seen in combined alcohol and drug units, although this percentage varies among the states. Many states now have an overwhelming majority of combined units reporting (e.g.,Pennsylvania, Louisiana, Michigan); only a few states have a greater number of alcoholism-only units reporting (e.g., New York, New Jersey, Rhode Island). The "unit locations variable in the survey (Table 4-2) identifies the type of organization within which a treatment unit is placed or the name by which it would commonly be known in the community. The unit location cannot precisely define the sector of which a unit is a part or the ideology to which a unit subscribes, but it can serve as an indicator of which organizational factors may contribute to the orientation of the treatment regimens offered. Thus, units located in community mental health centers are most likely to use the psychological model, units located in halfway houses are most likely to use the social model, and units located in hospitals are most likely to use the medical model. The survey used a matrix to obtain information on the types of treatment being received on the census date; "Facility Locations and "15rpe of Care" were the descriptors used. The two facility location categories that were available to respondents were hospital inpatient and nonhospital. The type of care is defined as the primary treatment approach or regimen to which staff have assigned the person seeking treatment. The definitions of the five types of care included in the 1987 NDATUS are as follows: Inpatient/Residential Detoxification (Medical)- The use of medication under the supervision of medical personnel to systematically reduce or eliminate the effects of alcohol in the body in a hospital or other 24-hour-care facility. Detoxification (Social)-The systematic reduction or elimination of the effects of alcohol in the body (returning the person to a drug-free state), in a specialized nonmedical facility by trained personnel with physician services available when required. Rehabilitation/Recovery-An approach that provides a planned program of professionally directed evaluation, care, and treatment for the restoration of functioning for persons impaired by drug abuse or alcoholism. In some states, this type of care is referred to as treatment or recovery (excluding detoxification). Custodial/Domiciliary-Provision of food, shelter, and assistance in routine daily living on a long-term basis for persons with alcohol or other drug-related problems. Outpatient/Nonresidential-Treatment/recovery/aftercare or rehabilitation services provided by a unit in which the person receiving treatment does not reside. The person may receive drug or alcoholism treatment services with or without medication, including counseling and supportive services. Day care is included in this category. Four of the types of care (medical and social detoxification, rehabilitation/recovery, and custodial domiciliary) are portrayed as taking place within 24-hour-care environments with persons residing at the treatment facility; only one (outpatient/nonresidential) is described as taking place in a setting where the persons in treatment do not reside. In
WHO PROVIDES TREATMENT? 123 keeping with current practice, detoxification is clearly identified as a separate stage and is further differentiated into social and medical model approaches. Rehabilitation is not differentiated in this manner. In general, the NDATUS definitions acknowledge the variations among the states in defining the continuum of care and the elements that constitute it. The definitions also include the recovery conceptualization, which is preferred in California as more accurately reflecting that state's nonmedical or social model of treatment (see Chapter 18~. Although the NDATUS is the major survey instrument available for gathering data on the treatment of alcohol problems, its usefulness is limited by the breadth of its categories and definitions. The type of care classification mixes what has been identified in this report as the orientation, stage, and setting of treatment. Consequently, the NDATUS data do not reveal which model was used for a particular individual's treatment or the stage of treatment of a person on the day of the census, even though (as discussed in Chapter 3) these are increasingly important distinctions for level of care placement and cost-efficient treatment. For example, the NDATUS differentiates between social and medical model for only the detoxification stage. The survey does not differentiate by orientation the rehabilitation and custodial/domiciliary types of care, although these variations exist (Borkman, 1986~. The available survey data also do not fully differentiate among the types of beds being utilized by persons in treatment on the day of the survey. Although detoxification is clearly distinguishable, the rehabilitation and maintenance stages are partially combined in the definition of hospital/residential rehabilitation/recovery type of care. The short-term rehabilitation unit and the halfway house or extended care facility cannot always be distinguished. Thus, the beds belonging to the type of care defined as rehabilitation/recovery could appropriately be in use for either primary rehabilitation and extended care or transitional care (halfway house). Another consequence of the construction of the survey is that it lumps together in the outpatient setting persons who are in differing stages of treatment. Individuals could have been in any of the stages on the census date. Moreover, the day-care, or intermediate, setting is not reported separately, but is included in the outpatient rehabilitation category, even though (as discussed in Chapter 3) day treatment is seen as an increasingly important cost-effective approach to both detoxification and primary care and can be used for maintenance and relapse prevention as well (e.g., Longabaugh et al., 1983; Frankel, 1983~. Similarly, the outpatient environment slots could be in use for ambulatory detoxification, primary rehabilitation, extended care, or relapse prevention and supportive maintenance, as well as for treatment of those medical or psychiatric complications that can be dealt with in an ambulatory status. Of the individuals reported in the survey, the majority (299, 679, or 85 percent) was enrolled in the outpatient/nonresidential rehabilitation/recovery type of care. The remainder was enrolled in one of the four inpatient programs: 10,507 in detoxification (4,015 in the 390 units that reported offering medical detoxification; 6,492 in the 939 social detoxification units); 37,739 in the 2,185 rehabilitation/recovery programs; and 2,688 in the 182 custodial/domiciliary programs. The data also show that there are units offering medical model detoxification in every state except Vermont; there are social model detoxification units reported in all states except the District of Columbia, Maine, North Dakota, West Virginia, and Wyoming. ~ ~ ~~ Every state has units offering outpatient and inpatient/residential rehabilitation. There are custodial/domiciliary units in all but eight states: Delaware, Hawaii, Michigan, Montana, New Jersey, North Dakota, West Virginia, and Wyoming. As noted earlier, the NDATUS data do not show whether an individual was in outpatient detoxification, primary treatment, or aftercare on the day of the census. To compensate for this kind of aggregation some outpatient units appear to have attempted at least to categorize some of their clients in a detoxification status: 15 outpatient units
124 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS reported providing social model detoxification for 69 persons and 8 outpatient units reported providing medical model detoxification for 105 persons. The actual level and geographic distribution of ambulatory detoxification or rehabilitation services are not avail- able because of the overly broad definitions for facility location and type of care used. Any attempt to define and organize the various types of treatment or care available for persons with alcohol problems must recognize that any given form of organization can provide different stages of care in each setting using any single treatment modality or a mixture of modalities. The NDATUS should be redesigned to Effect actual practice more accurate, and to identity chard which types of treatment are being provided. The term ownership is used in the NDATUS to describe the type of organization that is legally responsible for the unit's operation. The survey uses four categories: (1) for profit, which includes individuals, partnerships, and corporations; (2) not for profit, which includes church-related groups, nonprofit corporations, or other forms of nonprofit organization; (3) state and local government, which includes all forms of such organization; and (4) the federal government, which includes any federal agency. The NDATUS ownership category is similar to the ownership category in the American Hospital -a r ~7 ~ ~ ~ Association's (1987) annual survey of hospitals; In that survey, ownership is divided Into federal and nonfederal groupings including state and local government, nongovernment/not for profit, and investor owned/for Profit. Substantial differences in the models of services offered and the types of persons treated In programs In each or finest ownersn~p groups have been suggested (Jacobs, 1985; Miller and Hester, 1986: Yahr, 1988; see Appendix D). Privately operated units constituted the majority (81 percent) of the respondents in the 1987 NDATUS (16 percent were private/for profit, and 66 percent were private/not for profit). The third largest category (16 percent) was state- and local- government-operated programs. The trends noted in prior surveys continued: there was an increase in the proportion of private programs (both for-profit and not-for-profit types) and a decrease in the proportion of public (both state and federal government) programs (Reed and Sanchez, 1986; Yahr, 1988~. This trend must be interpreted very cautiously, however, because there is a substantial and as yet unexplained drop in the total number of programs that responded to the 1987 survey when compared with those responding to the 1984 NDAPI and with the number of programs estimated to be active from the 1987 survey of programs receiving funding from the state alcoholism authorities (Butynski and Canova, 1988~. The "underreporting is seen in both the 17 percent drop in the total number of programs responding to the survey (from 6,963 in 1984 to 5,791 in 1987) and in the 2 percent drop in the number of facilities responding to the question on ownership (from 5,791 to 5,667~. There are several possible reasons for the drop. The extensive outreach efforts conducted for the 1984 survey may have resulted in a higher response rate. There are also some changes in the 1987 survey in the way multisite programs are reported that may have contributed to the decrease in the number of units. In addition, despite its lack of specificity in other definitional areas, the 1987 NDATUS provided a more stringent definition of a treatment unit than that used in 1984 (NIDAINIAAA, 1989~. . · ~. . . Treatment Personnel Any discussion of the settings and organizations in which treatment services are provided must also deal with the personnel who perform the specific services and the levels of training, education, and experience that are needed to carry out the necessary treatment and administrative activities. Human resources utilization in the treatment of alcohol problems tends to be a matter of some controversy (Gunnerson and Feldman, 1978; Mitnick, 1978; USDHHS, 1981; Camp and Kurtz, 1982; Rosenberg, 1982; Saxe et al., 1983; Blum and Roman, 1985; Lewis et al., 1987; Bowen and Sammons, 1988; McGovern, 1988~.
WHO PROVIDES TREATMENT? 125 The major sources of this controversy are the historical failure of traditional health and mental health professionals to work effectively with people with alcohol problems and the filling of this void by lay persons, primarily recovering alcoholics, who had by the 1960s begun to develop their own programs using the principles of Alcoholics Anonymous (D. J. Anderson, 1981; Bissell, 1982; McGovern and Armstrong, 1986~. The net result of these two phenomena is that, along with the development of nontraditional treatment programs in the specialty sector, there has been a shift in the usual alignment of roles and responsibilities in the treatment of alcohol problems that has not yet been consolidated into a singular approach to human resources planning and training. During the 1970s, the field went through an initial rapid expansion in the role of and reliance on the alcoholism counselor as the primary therapist, or case manager, and program administrator. Alcoholism counselors became the dominant treatment staff working in organized programs funded by NIAAA and the states. However, Saxe and colleagues (1983) noted the change that has taken place in recent years: a reinfusion of psychologists and psychiatrists into the alcohol treatment work force in the late 1970s after the development of the network of nonmedical programs in the 1960s and early 1970s. In those programs, counselors had occupied the roles of primary therapist, administrator, milieu management and support staff, outreach worker, diagnostician, and advocates for development. Today, given the need to develop programs that could receive third-party health insurance funding, program accreditation standards often require that physicians take on supervisory and administrative responsibility for clinical operations and that treatment be carried out only by primary therapists who meet specific educational or licensing standards. This shift has led to a transitional period in which many of the personnel working in the field are identified as "alcoholism counselors regardless of their original discipline and training, and in which the nondegreed, recovering person who has become a counselor or administrator is feeling shunted aside by the professionals and the funding agencies. There was no national policy or program for developing a coherent human resources system for the treatment of alcohol problems until 1979 when NIAAA's State Manpower Development Program was initiated (Camp and Kurtz, 1982; Ziener, 1988~. This program provided categorical grant funding to each of the state alcoholism authorities to develop a manpower plan and to conduct training of treatment providers. The program ended with the incorporation of all NIAAA categorical grants into a block grant in 1982 (see the discussion in Chapter 18~; the block grant does not require states to continue this effort and most states no longer produce a plan (W. Butynski, National Association of State Alcohol and Drug Abuse Program Directors, personal communication, 1988; B. Meyers, Colorado State, Alcohol and Drug Abuse Division, personal communication, 1988; Horizons Technology Inc., 1988~. During the years of its implementation, however, the State Manpower Development Program produced an annual human resources plan for alcohol treatment, using information collected by the states from treatment providers on their needs for personnel and for training activities. An assessment was also made of the demographic makeup of the work force to determine its representativeness and compatibility with the persons being served (Macro Systems, Inc., 1980~. Currently, each state and each involved discipline develop their own policies, and the degree of activity among the states and disciplines varies considerably. Among the most active are the American Medical Society on Alcoholism and Other Drug Dependencies (Galanter and Bean-Bayog, 1989), the American Psychiatric Association (Galanter et al., 1989), the Association for Medical Education and Research in Substance Abuse, and the National Association of Alcoholism and Drug Abuse Counselors (McGovern, 1988~. The most recent national survey of personnel employed in facilities that offer treatment for alcohol problems was conducted in 1982 (NIAAA, 1983a). (After a hiatus
126 BROADENING IlIE BASE OF TREATMENT FOR ALCOHOL PROBLEMS of seven years, questions to solicit these data will again be included in the 1989 NDATUS.) In 1982 there were 44,098 total paid and volunteer staff working in the 2,734 alcoholism-only treatment units reporting. There were a total of 31,520 paid, full-time employees (generally referred to as FTEs, or full-time equivalents, for the purposes of quantification). The three largest general categories of workers in treatment programs were counselors, nurses, and administrative and support staff. Administrative and support staff accounted for 26 percent of the P 1 IS reported in the 1982 survey, and direct care staff accounted for the remaining 74 percent. The distribution of direct care employees was analyzed by discipline rather than by function or role. The largest direct care staff group was counselors (34 percent). The majority of the counselors (20 percent of the total) did not have a related academic degree; the remainder (14 percent) had either a counseling degree or some type of certification for counseling training. Physicians made up about 3 percent of the total staff and were most likely to be part time. Registered nurses constituted about 11 percent of the total staff pool, whereas other medical disciplines (e.g., licensed practical and vocational nurses, orderlies, pharmacists, and physicians' assistants) accounted for an additional 9 percent. Psychologists made up almost 3 percent and social workers, 4 percent. The remaining 12 percent were other direct care staff who were not identified with a discipline. In addition to physicians, doctoral-level psychologists were more likely to be part-time employees whereas counselors, master's-level psychologists, nurses, and social workers were more likely to be full-time employees. The 1982 survey showed that counselors, many of whom were recovering persons, had become the primary treatment service providers in many of the specialist programs and that they functioned with considerable autonomy in those settings. This situation is still the norm today. Although still identified as Alcoholism counselors" (or, increasingly, as Addictions counselors~), these personnel perform a variety of roles previously reserved for the other professional disciplines. In a given program an individual trained as a counselor may fill an administrative role (e.g., program director, unit supervisor), a clinical role (e.g., case manager, primary therapist, group therapist, psychodrama leader, family counselor, intake worker), or a milieu management role (e.g., residence supervisor, activity therapist, group leader). The widespread use of physicians to provide medical services in inpatient detoxification and rehabilitation programs has continued. A common pattern in freestanding residential rehabilitation programs and rehabilitation units in general hospitals is to have a single physician, or a physician group, serve as the medical director of the program or unit and assume the responsibility of attending physician for all those who are admitted. The physician is responsible for the development of the multidisciplinary treatment plan and for ensuring that the appropriate physical examinations and laboratory tests are carried out and that medications, if needed, are correctly administered and monitored. Psychiatrists perform these required medical functions in VA and psychiatric hospitals. Psychiatrists also provide consultations and specific services to persons in other settings who have coexisting psychiatric disorders. Nurses play key roles in staffing and administering medical model detoxification and rehabilitation programs. Nurses primarily provide direct services to persons admitted to inpatient detoxification and rehabilitation settings; they manage the medical treatment prescribed by 'the physician, retaining responsibility for the nursing care plan and management of the unit milieu. Nurses working in an inpatient unit participate in the alcohol education sessions and are often responsible for providing lectures on the physical consequences of excessive alcohol use. They also provide supportive counseling. Other nurses, with training-in psychotherapy and family counseling, have moved into counseling and administrative roles in all settings. The program director for a rehabilitation unit in a general hospital is often a nurse.
WHO PROVIDES TREATMENT? 127 Doctoral-level clinical psychologists are generally used on a part-time basis as diagnostic consultants, group therapists, and individual therapists. Master's-level psychologists may function in a similar fashion, but they are more likely to be full-time employees of the program rather than consultants. In a given program, an individual trained as a psychologist may also fill an administrative role (e.g., program director, director of clinical services) as well as a clinical or milieu management role. Social workers and counselors with master's degrees are widely used as primary therapists or case managers. Primary therapists coordinate the provision of services to an individual from intake (the admission evaluation) to follow up. They generally provide any individual therapy or counseling the person receives. In addition, social workers are also increasingly found in administrative roles as well as in clinical and milieu management roles. Many hospital and residential Programs. if they are large enough, further differentiate counseling roles. There may be an intake counselor, a primary counselor during the inpatient stay, and an aftercare counselor who is responsible for postdischarge follow-up. Increasingly there may also be a designated family counselor who leads family groups and works with individual families. Outpatient programs ordinarily do not have such a division of labor. The disciplines licensed for independent practice in their speciality (e.g., internal medicine, psychiatry, nursing, social work, marriage and family counseling, psychology) may also provide services within a private practice setting, in which they carry out the more traditional roles of diagnostician, case manager, and therapist as defined by their speciality. There are no data available on the number of private practice professionals who devote their entire practice to the treatment of persons with alcohol problems. Moreover, there are no data on the percentage of time that is devoted to treating persons with alcohol problems by the disciplines for whom such treatment is a part of their practice. Which discipline fills the various clinical, supervisory, and administrative roles in the operation of an organized treatment program depends on the program's philosophy and orientation (Kole and Mitnick, 1978~. In medical settings the functions or roles generally reflect the traditional medical hierarchy (Camp and Kurtz, 1982~. In nonmedical settings there is more shifting of responsibilities among personnel and many tasks that are seen as appropriate to personnel with different initial training, experience, and credentials. For example, the role of the physician as the primary treatment provider and supervisor has been challenged by advocates of the social model of detoxification and rehabilitation (Borkman, 1986~. In halfway houses and recovery homes, physicians and other professionals often serve as consultants or providers of a specific discipline-limited service rather than as care givers who are responsible for the overall treatment plan. Indeed, social model detoxification and rehabilitation programs and halfway houses are likely to be staffed with counselors who have varying degrees of experience and education. The key role played by alcoholism counselors in the administration and delivery of treatment in publicly supported programs has created problems in financing such treatment through traditional public and private insurance mechanisms (Camp and Kurtz, 1982; Lawrence Johnson and Associates, Inc., 1983~. Efforts to develop credentialing for alcoholism counselors were a key part of the federal strategy to obtain stable funding for the treatment of alcohol problems and were actively pursued until the shift to block grant funding in 1982. At that time, with federal assistance, more than 34 states had developed mechanisms for certifying counselors, either through the state alcohol agency or through a statewide voluntary association. Since 1982 there have been sporadic efforts aimed at developing a national credentialing system, but they have met with little success. This effort is now continuing under the leadership of the National Association of Drug and Alcohol Counselors (McGovern, 1988~. ~O ~ ~,
28 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Present estimates are that approximately twenty thousand professionals describe themselves as alcoholism or alcoholism and drug abuse counselors. The National Association of Alcoholism and Drug Abuse Counselors currently has a membership of 11,000 persons who work in treatment programs in a variety of educational, corrections, health care, and other settings. Counselors, rehabilitation therapists, administrators, social workers, psychologists, nurses, and physicians, including psychiatrists, constitute the association's membership. A survey conducted as part of an NIAAA-sponsored effort to develop model standards for credentialing counselors (see the discussion later in this chapter) reported the following breakdown of professions under the umbrella of alcoholism counseling: counselors 60 percent, rehabilitation therapists-7 percent, administrators 4 percent, social workers-9 percent, psychologists-7 percent, nurses percent, and physicians~.4 percent (Birch and Davis Associates, Inc., 1984) . The two disciplines that have been most active in the last several years in attempting to continue these early credentialing efforts have been counselors and physicians. For alcoholism counselors the aim has been to gain legitimization and acceptance as a professional discipline. For physicians the aim has been to both increase the amount of training that all physicians receive so that fewer persons with alcohol problems will go undetected in primary care settings (USDHHS, 1986; Cotter and Callahan, 1987; Lewis et al., 1987; Bowen and Sammons, 1988) and to develop an acceptance of the treatment of alcohol problems as an area of specialization (Galanter and Bean-Bayog, 1989~. J. E. Royce (1981) traced the origins of the new profession of alcoholism counseling to the incorporation of recovered alcoholics into the treatment team at the Yale Plan Clinic in 1944. The role of the counselor was further developed at Minnesota's Willmar State Hospital in the early 1950s in a program in which recovered alcoholics with native counseling ability were used to provide treatment. The role of the alcoholism counselor continued to be refined as part of the development of the Minnesota model (see Chapter 3) at Willmar State Hospital and its subsequent use at the Hazelden Treatment Center (D. J. Anderson, 1981; Emanuel, 1984~. In 1954 the Minnesota Civil Service Commission, designated the alcoholism worker or counselor as a formal employment category, a step D. J. Anderson (1981) considered to be a significant achievement in the development of counseling during this period. There were parallel developments in other parts of the country as more and more programs began to use recovering persons to provide treatment (Camp and Kurtz, 1982~. The growth of community mental health centers and community health centers, both of which used nondegreed workers in community outreach programs, greatly influenced the acceptance of the alcoholism worker (counselor) as a paraprofessional (Kole and Mitnick, 1978; Mitnick, 1978) during a time when the established helping professionals showed little interest in the field of alcohol problems. As a result more and more of the treatment enterprise was born by the recovered alcoholism worker. Staub and Kent (1973) describe in detail the development of the role of the alcoholism worker as a paraprofessional. The increasing responsibility for carrying out treatment assumed by these recovered persons was not unquestioned. The Krystal-Moore controversy (Krystal and Moore, 1963) regarding the personnel qualified to treat the person with alcohol problems is illustrative of the tension that existed between degreed professionals and nondegreed workers in the field. Krystal's position was that only trained professionals were qualified to treat persons with alcohol problems. He argued that alcoholism was a symptom of an underlying emotional problem that required psychotherapy conducted by professionals with additional specialized training. Moore's position was that individual psychotherapy was not the most effective form of treatment for the vast majority of persons with alcohol problems; rather, treatment for alcohol problems required the involvement of all disciplines in seeking the appropriate use of their skills through more
WHO PROVIDES TREATMENT? 129 effective techniques. Many psychiatrists agreed with Moore that counselors who were recovering persons had an important role to play in the treatment of alcohol problems (Lemere et al., 1964~. C. M. Rosenberg (1982) described the typical paraprofessional alcoholism counselor in 1971 as a 40-year-old man who was addicted to alcohol but who had gained significant sobriety through involvement with Alcoholics Anonymous. Rosenberg considered such a person a paraprofessional, owing to limited education and the lack of formal academic and clinical qualifications in one or the other of the health professions. The rapid growth of a cadre of paraprofessionals (counselors) who were often without formal education credentials but who were trained in counseling skills that met the needs of their clients in task-oriented group environments was a remarkable feature of the development of all human services in the 1960s and 1970s and not just the treatment of alcohol problems (Mitnick and Kole, 1978; D. J. Anderson, 1981~. The negative attitudes of established health care professionals (physicians, nurses, social workers, and clergy) toward working with the "alcoholics paradoxically fostered the growth of the new profession. The passage of alcoholism counseling from a paraprofessional to a somewhat more professional standing is reflected in a report to NIAAA that was commissioned to develop proposals for national standards for alcoholism counselors (Roy Littlejohn Associates, Inc., 1974~. The Littlejohn study described the counselor as a key member of a prevention/- treatment/rehabilitation team in programs where persons with alcoholism problems receive help. Alcoholism counseling, according to the Littlejohn study, was a "new professions that embraced a wide range of tasks: intake, crisis intervention, individual and group counseling, education and prevention, and program development and consultation. Counselors were now seen as full-time paid professionals who were distinguishable from members of lay or volunteer organizations such as AA The 1970s brought the development of state and national counselor organizations together with the emergence of certification and credentialing initiatives (Kole and Mitnick, 1978; Birch and Davis Associates, Inc., 1984~. By the end of the 1970s counselors were providing most of the direct counseling services to persons with alcohol problems and their families. In their professional role, counselors functioned as essential members of multidisciplinary teams in a variety of settings. Nondegreed counselors performed many of the case management and psychotherapy functions that had previously been seen as reserved for physicians, psychologists, and social workers. Much of the effort in the alcohol counseling arena during the 1980s has been centered on the development of professional standards and procedures for credentialing counselors. At the national and state levels, various components of the alcohol problems field have addressed this issue. Currently, in 34 states, counselors are credentialed by either the state alcoholism authority or by a voluntary organization. Although the standards and procedures are similar, there has been no success achieved in developing a single set of standards to be used in all states or in having all the states recognize those individuals who are credentialed in other states. A uniform plan for credentialing that guarantees reciprocity among the states has been developed by the groups that constitute the Certification Reciprocity Consortium-Alcohol and Other Drug Abuse. In addition, the National Commission on Credentialing of Alcoholism and Drug Abuse Counseling represents key constituency groups that share a common interest in facilitating the implementation of a national competency-based credentialing system. The acceptance and implementation of such national standards may be the critical issue that ultimately determines the professional status and growth of alcoholism counseling (McGovern, 1988~. The Birch and Davis Associates report (1984), the outcome of the NIAAA initiative to develop model professional standards for counselors, is of great significance in this area. As part of the larger project, two national surveys of practicing alcoholism and drug counselors were conducted; counselors were asked to identify which activities were the
130 BROADENING DIE BASE OF TREATMENT FOR ALCOHOL PROBLEMS core tasks of their job and what knowledge and skills were required to carry out those tasks. The respondents to the Birch and Davis survey, regardless of differences in practice settings, work experience, educational background, and life experiences consistently agreed in the ranking of the tasks, knowledge, and skills appropriate to alcoholism counseling. Two separate validation studies produced three major core products: (1) a set of counselor job tasks, (2) a body of knowledge and skills that reflects the competencies the counseling field expects of its practitioners, and (3) guidelines on techniques to assess the competencies of individuals seeking a counselor credential. Competencies in core functions, which are identified as screening, intake, orientation, assessment, treatment planning, individual group and significant other counseling, case management, crisis intervention, client education, referral, reports and recordkeeping, and consultation with other professionals in regard to client treatment services, were defined as requirements for certification. One consequence of the credentialing and professionalizing efforts of the past decades are dramatic changes that have occurred in the counseling field over the past 10 years. At the end of the 1970s most counselors were male, 45 years old, in recovery, and with little formal education beyond high school. Today's counselors are younger, with a higher representation of women, and are more likely to have academic training; fewer are in recovery (60 percent), and they have higher rates of certification (Birch and Davis Associates, Inc., 1984; Blum and Roman, 1985; McGovern, 1986, 1988~. Another debate of the 1970s was whether a counselor had to be a recovering alcoholic to be effective. Now, many more treatment settings use recovered counselors and nonalcoholic counselors, and McGovern and Armstrong (1986) argue that recovered and nonalcoholic counselors now espouse common goals born of a common philosophy of treatment. Studies show that both groups are equally effective, given appropriate training (Blum and Roman, 1985; McGovern and Armstrong, 1986~. In addition to the movement toward credentialing and professionalizing counselors, independent efforts have been proceeding to develop both specialized training and credentialing mechanisms for each of the major academic disciplines involved in the treatment of alcohol problems (Galanter and Bean-Bayogg, 1989~. A variety of professional associations has arisen to bring together workers from the various disciplines who specialize in treating persons with alcohol problems. Each of these groups has taken positions on what they consider to be the optimal configuration of treatment services and personnel, and some have been involved in developing their own credentialing procedures. In particular, the training of physicians as specialists in the treatment of alcohol problems and as generalists who are sensitive to alcohol problems has long been an NIAAA priority, and there has been significant progress in the development of physician training programs in diagnosis and referral for alcohol problems. One of the initial efforts in this~area was the Career Teacher Program, launched in 1971 and sponsored by NIAAA and NIDA (Lewis, 1989~. This program laid the groundwork for nationwide changes that are now occurring in medical education about alcohol problems. It provided a shared experience for participating faculty members throughout the country in curriculum content and issues of effective teaching, as well as in ways to overcome the negative attitudes of students, faculty, and institutions toward treating persons with alcohol problems. Its products included teaching monographs, educational materials, and the development of curriculum objectives. Surveys on the impact of the program, which ended in 1981, showed that elective courses in substance abuse tripled at Career Teacher schools, but required courses still remained at fewer than 1 percent of the total curriculum. The federal initiative was renewed again in 1985 with support for a national conference sponsored jointly with the Association for Medical Education and Research in Substance Abuse (AMERSA), which grew out of the Career Teacher Program. The conference was organized as a consensus activity to define the minimal knowledge and
WHO PROVIDES I'REATMENI? 131 skills that various medical disciplines should possess (e.g., pediatricians, internal medicine, family medicine) and also to define the minimal knowledge and skills all physicians should possess in diagnosis and referral for alcohol and other drug problems (Alcohol, Drug Abuse, and Mental Health Administration, 1985~. It attracted medical leaders from universities, national professional societies, and the Public Health Service and formed a consensus that was the basis for a new federal contract program to develop and implement model curricula for medical students and residents. As a result of these efforts, there is now a clearer understanding of the curricular content needed (and the most effective means of teaching this content) to develop the essential alcohol problems-related knowledge and skills for all physicians across specialities and in particular for the disciplines of pediatrics, family medicine, and internal medicine. In addition, contracts have recently been awarded to schools of nursing to define that profession's teaching needs and to develop a model nursing curriculum. NIAAA and NIDA have also launched a new grant program that establishes a medical and nursing faculty fellows program to enlarge and improve alcohol- and drug-related clinical training. All of these recent efforts by the federal government are in response to a growing interest among the general public and medical professionals concerning these training issues (Bowen and Sammons, 1988~. Part of the renewed interest in medical training related to alcohol problems has come from groups interested in primary care, including such national professional societies as the Society of General Internal Medicine, the Society of Teachers of Family Medicine, and the Ambulatory Pediatric Association. These organizations, which are committed to providing quality primary care of common problems, recognize the pervasiveness and heterogeneity of alcohol problems and the sorts of interventions that may be effective, including the kind of brief advice and treatment discussed elsewhere in this report (see Chapter 9~. These national professional societies have formed active task forces and have joined with the American Medical Association as cosponsors of the annual AMERSA national conference. All of these developments in medicine and nursing point to a new breed of practitioner who will have received formal education about alcohol problems and who will be able and willing to identify and treat alcohol problems or to refer individuals for specialist treatment. This new breed of practitioners will join the cadre of trained professionals- physicians, nurses, counselors, social workers, and clinical psychologists-already at work providing treatment for alcohol problems. Unfortunately, the dimensions of this cadre are unclear because there is a serious lack of accurate, timely work force data at the national level. This lack of data compromises efforts to plan for future training and professional needs. Fundamental questions for each of the disciplines involved cannot be answered: for example, the backgrounds and characteristics of persons working in the field, whether they are working in the specialty alcohol problems treatment sector or in the related primary health, corrections, education, mental health, or social services sectors; the nature of their long-term career opportunities; and whether there is currently growth or constriction in the number of specialized training programs. As a consequence, it is not possible to formulate a forward-looking work force training policy. Currently, there is no national group or agency charged with gathering work force data and with formulating an appropriate policy on training and credentialing. During the process of completing the report the committee learned that staffing information was to be added to the NDATUS. This addition is a positive development but will only provide data for the specially treatment sector. Such data needs also to be collected from the nonspecialist sector. Recent federal legislation (the Anti-Drug Abuse Act of 1988) gives the clinical training responsibility for counselors and health professionals to ADAMHA's Office of Substance Abuse Prevention (OSAP), suggesting that there will be a renewed federal interest and effort (Horizons Technology, Inc., 1988~. Under an interagenc y agreement, OSAP will focus on the training of counselors and health
132 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS professionals already in the field, and NIAAA and NIDA will continue and expand their efforts to educate health professionals at the the graduate school and continuing education levels. Given the lack of concerted, coordinated human resources planning and the questions that continue to be raised about the roles each discipline should play in delivering and in administering treatment for alcohol problems, there appears to be a need to reestablish a untidied work force planning exhort. The first steps in such planning should be accurate determinations of the staffing in existing specialist programs and the role or roles currently played by each discipline. Summary and Conclusions Persons with alcohol problems receive care in a wide variety of generalist organizations, as well as in organizations that specialize in treating alcohol problems. A description of either the specialist service delivery system or the generalist system is difficult because there has not yet been an acceptable comprehensive classification that fully incorporates the developments of the last 20 years. One major development has been the tremendous expansion of institutional and community-based treatment programs, both within traditional agencies (e.g., general hospitals) and nontraditional agencies (e.g., freestanding social settin~oxification centers). There also appear to be an increasing number of private practitioners working in the field of alcohol problems. Treatment is provided by personnel from a variety of disciplines including physicians, social workers, counselors, and psychologists. There have been redefinitions of the roles played by each discipline in more traditional health care facilities, but, in all of the organized settings, alcoholism counselors have become the major providers of treatment. Even though there has been a major effort to obtain increased acceptance of the treatment for alcohol problems as belonging within the mainstream of health care services, many of these newer agencies are not in traditional health care settings and do not follow what have become the established patterns of staffing and functioning. This variation has contributed to problems in describing who is providing what kind of treatment to whom. Some of the agencies focus on providing one type of care (e.g., social setting detoxification, hospital-based rehabilitation]: others attempt to offer comprehensive health and social ---rig ~ 1 ~ services during all stages of treatment to a special population (e.g., tne Salvation Army, Indian Health Service). The dominant historical influence on the field has been its origins in the integration of Alcoholics Anonymous philosophy and professional concepts now known as the Minnesota model and exemplified by the pioneering work at Willmar State Hospital, the Hazelden Foundation, and the Yale Plan Clinics. Alcoholics Anonymous itself continues as the best-known provider of support and treatment for alcohol problems. Although is possible to draw a broad outline of the service delivery system for the treatment of alcohol problems and to describe some of its components, it is not possible to accurately identity who provides what types of treatment to whom because of the lack of systematic surveys and studies. The evolving network of service providers (both programs and personnel) and the relationship of provider characteristics to the availability, conduct, and outcome of treatment have not been adequately described or studied (Gilbert and Cervantes, 1988; Wallen, 1988~. An expanded research program is needed to investigate the social ecology of the treatment system (Weisner and Room, 1984; Weisner, 1986~. In developing its analysis of the treatment system, the committee has been hampered by the lack of studies on a number of important topics: the impact of the organizational, ideological, and financial characteristics of treatment providers; their interrelationships; their relationships to referral sources; and the impact of various funding strategies on the organization, utilization, and outcome of treatment. More research is needed; examples of
WHO PROVIDES TREATMENT? ~ 22 studies that should be replicated and expanded are (a) examination of the trends in the profiles of offered services that are associated with ownership type (Yahr, 1988), (b) examination of the utilization of different services by the various special population groups (Gilbert and Cervantes, 1988), and (c) examination of trends in reimbursement sources for different types of specialty programs (Creative Socio-Medics Corporation, 1981~. Performing such studies will require surveys that are better designed and better conducted than the major vehicle now available, the National Drug and Alcohol Treatment Unit Survey. Studies of service profiles and of the outcomes associated with different paths through the treatment system are also needed. Specifically, research should investigate the value of providing increased intermediate care (day-care) options at each stage of treatment and of providing social model treatment. Private and public health insurance tend not to recognize day-care programs, halfway houses, or recovery homes as eligible providers, thus cutting off from coverage those persons needing such care. These programs generally are a mixture of the social and medical models, offering social support, vocational rehabilitation, and medical services along with primary treatment. 77ze committee sees an Hanson of intermediate care programs as an important element in increasing treatment availability and effecfiveness. Any studies of the organizations in which treatment services are provided must also analyze who performs the specific services. Human resources utilization in the treatment of alcohol problems continues to be somewhat controversial. One of the major aspects of this controversy is whether recovering persons, who in many cases have developed their own programs outside the health care mainstream, should continue to fill the void left by traditional health and mental health professionals in treating people with alcohol problems. Along with the development of nontraditional treatment programs in the specialty sector, there has been a shift in the usual alignment of staff roles and responsibilities that has not yet been consolidated into a single approach to human resources planning, training, and credentialing. Without a national policy or program for developing such an approach, each state and involved discipline currently develop their own policies. The degree of activity and the particular mechanisms used vary considerably among these bodies. Given the lack of concerted, coordinated human resources planning and the questions that continue to be raised about the roles each discipline should play in delivering and administering treatment for alcohol problems, there appears to be a need to reestablish a unified manpower planning effort. The first step in such planning is accurate determinations of the staffing in existing specialist programs and of the role or roles currently played by each discipline in programs in both the specialist and nonspecialist sectors. Additional research is required to determine the nature and level of treatment services being provided by each of the disciplines in the generalist health, social services, education, and corrections sectors as well as in the specialist alcohol problem treatment sector. REFERENCES Ablon, J. 1982. Support system dynamics of Al-Anon and Alateen. Pp. 987-995 in Encylopedic Handbook of Alcoholism, E. M. Pattison and E. Kaufman, eds. New York: Gardner Press. Al-Anon. 1986. First Steps: Al-Anon . . . 35 Years of Beginnings. New York: Al-Anon Family Group Headquarters. Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA). 1985. Consensus Statement from the Conference on Alcohol, Drugs, and Primary Care Physician Education: Issues, Roles, Responsibilities, Rancho Mirage, California, November 12-15. Rockville, Md.: ADAMHA
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136 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Dibello, G. A. W., G. W. Weitz, D. Poynter-Berg, and J. L. Yurmak. 1982. Handbook of Psychiatric Partial Hospitalization. New York: Bruner-Mazel. Diesenhaus, H. I. 1982. Current trends in treatment programming for problem drinkers and alcoholics. Pp. 219-290 in Prevention, Intervention, and Treatment: Concerns and Models, J. de Luca, ed. Washington, D.C.: U.S. Government Printing Office. Diesenhaus, H. I., and R. Booth, eds. 1977. Cost-Benefit Study of State Hospital Drug and Alcohol Treatment Programs. Report submitted to the Joint Budget Committee, Colorado State Legislature, Denver. December. Emrick, C.D. 1987. Alcoholics Anonymous: Affiliation processes and effectiveness as treatment. Alcoholism: Clinical and Experimental Research 11:416423. Emrick, C. D. 1989a. Alcoholics Anonymous: Emerging concepts. Pp. 3-10 in Recent Developments in Alcoholism: Emerging Issues in Treatment, vol. 7, M. Galanter, ed. New York: Plenum Press. Emrick, C. D. 1989b. Alcoholics Anonymous: Membership characteristics and effectiveness as treatment. Pp. 37-53 in Recent Developments in Alcoholism: Emerging Issues in Treatment, vol. 7, M. Galanter, ed. New York: Plenum Press. Errera, P., E. Nightingale, J. O. Lipkin, and M. L. F. Ashcroft. 1985. DRGs and psychiatry: Work in progress. General Hospital Psychiatry 7:316-320. Finn, P. 1985. Decriminalization of public drunkenness: Response of the health care system. Journal of Studies on Alcohol 46:7-22. Frankel, G. 1983. Alcoholism treatment in the partial hospital or day program. Alcohol Health and Research World 7~3~:32-36. Galanter, M., and M. Bean-Bayog. 1989. A study of physicians certified in alcohol and drug dependence. Alcoholism: Clinical and Experimental Research 13:1-2. Galanter, M., E. Kaufman, Z. Taintor, C. B. Robinowitz, R. E. Meyer, and J. Halikas. 1989. The current status of psychiatric education in alcoholism and drug abuse. American Journal of Psychiatry 146:35-39. Gallant, D. M. 1988. Alcoholism: A Guide to Diagnosis, Intervention, and Treatment. New York: Norton. Gilbert, M. J., and R. C. Cervantes. 1986. Alcohol services for Mexican Americans: A review of utilization patterns, treatment considerations and prevention activities. Hispanic Journal of Behavioral Sciences 8:1~0. Gilbert, M. J., and R. C. Cervantes. 1988. Alcohol treatment for Mexican Americans: A review of utilization patterns and therapeutic approaches. Pp. 199-231 in Alcohol Consumption among Mexicans and Mexican Americans: A Binational Perspective, M. J. Gilbert, ed. Los Angeles: Spanish Speaking Mental Health Research Center, University of California, Los Angeles. Glaser, F. G., and A. Ogborne. 1982. Does A. A. really work? British Journal of Addictions 72:123-129. Grad, F. P., A. L. Goldberg, and B. A. Shapiro. 1971. Alcoholism and the Law. Dobbs Ferry, N.Y.: Oceana Publications. Gunnersen, U., and M. L. Feldman. 1978. Alcohol and Alcoholism Programs:. A Technical Assistance Manual for Health Systems Agencies. San Leandro, Calif.: Human Services, Inc. Harrison, P. A., and N. G. Hoffmann. 1986. Chemical Dependency Inpatients and Outpatients: Intake Characteristics and Treatment Oucome. Prepared for the Chemical Dependency Program Division, Minnesota State Department of Human Services. St. Paul, Minn.: St. Paul-Ramsey Foundation. HaIwood, H. J., P. Kristiansen, and J. V. Rachal. 1985. Social and economic costs of alcohol abuse and alcoholism. Issue Report No. 2. Research Triangle Institute, Research Triangle Park, N.C. Horizons Technology, Inc. 1988. Prevention Training: Final Report. Prepared for the Office of Substance Abuse Prevention of the Alcohol, Drug Abuse, and Mental Health Administration. Oakton, Va.: Horizons Technology, Inc., October 3.
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