Broadening the Base of Treatment for Alcohol Problems (1990) / Chapter Skim
Currently Skimming:
Chapter 3--What is treatment?
Chapter 3--What is treatment?
Pages 42-97
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 42... ...
Are social model recovery centers and halfway houses treatment for alcohol problems? Is providing a supportive, alcohol-free living environment for homeless persons with alcohol problems treatment?
|
From page 43... ...
Supportive activities are seen as required if relapse is to be avoided and continued sobriety and recovery are to be maintained by individuals who have few personal and social resources and who are experiencing very severe physical, vocational, family, legal, or emotional problems around their use of alcohol (e.g., Boche, 1975; Kissin, 1977b; Costello, 1982; McClellan et al., 1980; Pattison, 1985; Moos and Finney, 1986/1987~. Socially deteriorated public inebriates or homeless alcoholics do require many additional supportive services if they are not to relapse and return to destructive alcohol consumption (Blumberg et al., 1973; Costello et al., 1977; Costello, 1980, 1982; Pattison et al., 1977; Shandler and Shipley, 1987; IOM, 1989~.
|
From page 44... ...
Rather, they represent an approach that, although long advocated, has not been systematically applied in the design of funding policies and effective treatment programs. Refining the Definition of Treatment for Alcohol Problems Treatment for alcohol problems has come to include a very broad range of activities that vary in content, duration, intensity, goal, setting, provider, and target population.
|
From page 45... ...
Treatment activities involve intervention after the development and manifestation of alcohol abuse and alcoholism in order to arrest or reverse their progress, and/or to prevent progressive illness or death from associated medical conditions.
|
From page 46... ...
Therefore, intervention programs which offer referral, education, and short term counseling as well as continuity of care assurance and follow-up monitoring (e.g., employee assistance programs, student assistance programs) are included in the committee's definition of the treatment system, along with more traditional locales (e.g., hospital and freestanding detoxification and rehabilitation units, outpatient clinics, halfway houses)
|
From page 47... ...
Generally staffed by a physician, a nurse, and a social worker, these specialty clinics provide a combination of clinical diagnosis of alcohol problems, medical treatment and counseling about the effects of continued excessive alcohol use, dietary counseling, health education, family counseling, and assistance in resolving social and legal problems. The focus of the clinics' education and counseling is that excessive alcohol consumption is the primary source of the patient's physical health, work, and family problems; sobriety or temperance, rather than abstinence only, are stressed as the means of eliminating these problems.
|
From page 48... ...
The approach it described was derived primarily from the continuum of care that had been developed over the years in Minnesota (Anderson, 1981; Research Triangle Institute, 1985~: A comprehensive alcohol treatment program provides care that recognizes the physical, social, psychological, and other needs of the patient. The major components of a comprehensive continuum of care approach are recognition, diagnosis and referral, detoxification, primary residential treatment, extended care, outpatient care or day care, aftercare, and a family program.
|
From page 49... ...
Recently, the New York state alcoholism authority developed a new model to describe its view of the ideal continuum of care. The new plan introduced a more comprehensive emergency treatment element, the alcohol crisis center, which replaces the sobering-up station; the plan also maintains a reduced hospital detoxification element (New York Division of Alcoholism and Alcohol Abuse, 1986~.
|
From page 50... ...
The federal government has implicitly defined its existing continua of care through the policies of the various federal agencies that fund and/or operate treatment programs (e.g., the Veterans Administration, the Department of Defense, the Health Care Financing Administration, the Alcohol, Drug Abuse, and Mental Health Administration) and through the definitions used in its national surveys.
|
From page 51... ...
A variety of models have been identified as guiding the development of treatment for alcohol problems-for example, the disease model endorsed by the majority of treatment programs, the social learning model developed by behavioral psychologists (Nathan, 1984; Donovan and Chancy, 1985) , and the social-community model of recovery that is now widely used in California (Borkman, 1986, 1988~.
|
From page 52... ...
The most prominent example of the use of the sociocultural model in formal treatment is the California social model of recovery (see the discussion later in this chapter)
|
From page 53... ...
Sociocultural factors may include variations in drinking norms and expectations, in work environments, and in family structure. The biopsychosocial model recognizes that, for each individual, all three sets of factors are potentially involved but that in different individuals one or the other sets of causes may predominate.
|
From page 54... ...
Rehabilitation orientation was measured by the frequency of use of relationship therapy, family therapy, occupational therapy, and vocational counseling, and by the number of staff who were psychologists, social workers, rehabilitation counselors, and occupational or recreational counselors. The unit's peer group or sociocultural orientation was determined by measuring the frequency of the use of alcohol education, Alcoholics Anonymous, and Al-Anon; the level of self-government activity; and the type of grievance activity.
|
From page 55... ...
treatment programs. The characteristic structure of the medical model is most evident in those hospital and nonhospital inpatient units in which the physician is either the primary therapist or is influential in determining the treatment plan to be carried out by an alcoholism counselor who acts as the primary therapist.
|
From page 56... ...
was also a reaction against what was seen as treatment taking place only within the short time frames of the structured program in the hospital or residential treatment center; in the social model, emphasis was placed on continued active involvement in the "social living space" of the alcoholic after discharge from the structured inpatient treatment program. The deemphasis on inpatient rehabilitation extended to detoxification; in addition, proponents of the social setting model of detoxification argued that pharmacologically assisted detoxification in the acute hospital setting, in which the alcoholic assumed the passive role of patient, actually interfered with the process of recovenr, the process of learning to live without relying on alcohol.
|
From page 57... ...
, among others. Current California social model programs are seen as third-generation mutual-help or self-help organizations that have evolved from the original first-generation efforts of Alcoholics Anonymous and the second-generation social setting detoxification centers, "Twelve Steps houses, halfway houses, and recovery homes that were founded by recovering alcoholics in the 1950s and 1960s (Rubington, 1974; Borkman, 1982, 1983; Orford and Velleman, 1982~.
|
From page 58... ...
Although treatment programs continue to vary along ideological lines, the field has seen in recent years the evolution and emergence of hybrid programs that claim to reflect the biopsychosocial model. The major hybrid is the Minnesota Model of Chemical Dependence Intervention and Treatment (Laundergan, 1982)
|
From page 59... ...
This inpatient treatment center was the forerunner of Parkside Medical Services, which is now the largest single nongovernment provider of alcohol and drug abuse treatment services in the country, operating a nationwide network of hospital and freestanding facilities and units that subscribe to the Minnesota model philosophy.
|
From page 60... ...
These principles were also finding voice in many of the treatment programs that were being developed in other parts of the country simultaneously with the Minnesota model. These programs tended to follow a similar course, growing out of the union of recovering persons and professionals working in specialized programs in acute care or psychiatric hospitals.
|
From page 61... ...
In 1977 NIAAA funded Blue Cross/Blue Shield to determine the feasibility of providing private health insurance benefits for alcoholism treatment. To estimate the costs of specific benefit designs more precisely, this effort clearly differentiated between those procedures that addressed acute physical problems arising out of excessive alcohol consumption and those procedures that focused on alleviating the chronic problems that arise out of the compulsive use of alcohol.
|
From page 62... ...
(Boche, 1975:5) In keeping with the perspective of the Uniform Act, the task force asserted that the continuum of care must include supportive services to reduce the patient's personal and social impairments as well as primary treatment activities that focus on changing drinking
|
From page 63... ...
used a similar model of the treatment episode to organize her recommendations on how to perform and evaluate treatment. She divided the alcoholism treatment episode into four phases (identificationfintervention, detoxification, TABLE 3-1 Stages and Settings of the Contimuum of Care Component Function Acute intervention II Evaluation III Intensive intervention IV Stabilization V Maintenance VI Domiciliary Care Structure Medical or nonmedical detoxification unit Centralized diagnostic center Residential facility; Day program Halfway house Outpatient clinic; AA State hospital; Rescue mission
|
From page 64... ...
It can occur in a variety of settings from an acute care hospital to a social model detoxification center. If the patient is not intoxicated then rehabilitative care can begin.
|
From page 65... ...
Stage 2: Rehabilitation Evaluation and assessment the development of an individualized treatment strategy aimed at eliminating or reducing alcohol consumption by a thorough assessment of the person's physical, psychological, and social status and a determination of the environmental forces that contribute to the drinking behavior. Primary care the application of therapeutic activities to help the individual reduce alcohol consumption and attain a higher level of physical, psychological, and social functioning while in either independent living or in a sheltered living environment.
|
From page 66... ...
Primary care is a period in which the treatment is undertaken to initiate change in an individual's alcohol consumption, to uncover the root causes of the excessive drinking behavior, and to provide positive substitute behaviors. The extent of primary care will vary with the severity of impairment and can be categorized as a brief intervention or an intensive intervention.
|
From page 67... ...
This confusion has been engendered by the idea that "treatments is limited to a 28-day inpatient stay, the primary care treatment duration often found in programs subscribing to the Minnesota model. Aftercare thus came to mean arrangements made for the person discharged from formal treatment for continued informal support from self-help groups, a program alumni group, or informal, nonscheduled contact with the treatment program.
|
From page 68... ...
For all psychiatric illnesses as well as for alcohol and drug problems, hospitals and residential treatment centers now tend to be viewed as the appropriate setting for short-term crisis intervention, problem resolution, and stabilization (primary cares) ; continuing treatment is seen as being more appropriate to less expensive residential or outpatient settings (nextended cares)
|
From page 69... ...
Outpatient care is the provision of nonresidential evaluative and alcohol treatment services on both a scheduled and nonscheduled basis. The choice of treatment setting is related to a variety of factors, including the ability to pay, the severity of alcohol abuse and attendant problems, the ability to leave the home environment to be treated in inpatient settings, and the client's orientation toward help-seeking.
|
From page 70... ...
Common features of the hospital setting were the use of the medical model, removal from the environment that supported the excessive drinking, and a highly structured program offering a range of treatment modalities. The intermediate care setting grouped together all residential facilities (primarily halfway houses)
|
From page 71... ...
For example, Colorado developed its nonhospital community intensive residential treatment program licensure category for public- and private-sector programs (mixed medical-social setting models) as well as program standards for alcohol detoxification and rehabilitation units in licensed hospitals (medical model)
|
From page 72... ...
treatment or recovery setting for individuals who need more intensive care, treatment, and support than are available through outpatient settings or who can benefit from supportive social arrangements during the day. Outpatient The provision of nonresidential evaluative and treatment services on both a scheduled and nonscheduled basis.
|
From page 73... ...
Ouipat~em The provision of treatment for alcohol problems, comprising, as needed, medical services, nursing services, counseling, and supportive services for persons who can benefit from treatment available through ambulatory care settings while maintaining themselves in their usual living arrangements. Treatment Modalities The content of treatment is usually referred to as the technique, method, procedure, or modality.
|
From page 74... ...
The first approach, pharmacologically assisted detoxification, is identified with the medical model and is referred to as medical detoxification. The second approach is identified with the sociocultural model and is referred to either as nonmedical detoxification or social model detoxification.
|
From page 75... ...
When it was first introduced, disulfiram was routinely prescribed in many treatment programs to all persons who were admitted as part of the standard rehabilitation protocol. Because of its side effects and the potential of dangerous DERs in some individuals, questions about its relative effectiveness and safety have led to recommendations for its more selective use as an adjunct to other treatment modalities (Kwentus and Major, 1979; Noble, 1984; Schuckit, 1985; Forrest, 1985; Jaffe and Ciraulo, 1985; Liskow and Goodwin, 1987; Sellers, 1988~.
|
From page 76... ...
The results also highlight the need to investigate in more detail the factors associated with compliance: these researchers found that those men who did comply with the prescribed treatment regimen in all three conditions were more likely to remain abstinent than those who did not comply. Another class of drugs, psychotropic medications, are also used in rehabilitation and relapse prevention and can be said to decrease drinking by improving associated psychopathology (i.e., anxiety, depression)
|
From page 77... ...
One of the rationales for the use of antianxiety drugs is that they improve retention in ongoing treatment and relapse prevention efforts. Yet there has been a great deal of controversy regarding their use in long-term rehabilitation and relapse prevention because of their own dependence-producing properties (Jaffe and Ciraulo, 1985; Meyer, 1986; Gallant, 1987~.
|
From page 78... ...
There are, however, certain specific modalities that for descriptive purposes are identified with one or the other model because of the rationale for their use and effect. Behavioral tmatmer~ modalities The first clinical use of techniques derived from learning theory to reduce alcohol consumption was by the Soviet physician Kantorovich more than 50 years ago.
|
From page 79... ...
A variety of behavioral social skills training procedures has been developed by those who believe that excessive drinking is caused by the inability to perform to one's own satisfaction in interpersonal situations (Oei and Jackson, 1980, 1982~. Individuals are taught in either group or social settings how to respond in typical social encounters; sessions focus on such specific skills as how to express and receive positive and negative feelings, how to initiate contact, and how to reply to criticism.
|
From page 80... ...
During the treatment process, the person may also use an alcohol-sensitizing drug as additional protection (Annie and Davis, 1988~. Behavioral self-control training is another relapse prevention strategy that uses a set of self-management procedures designed to help individuals stop or reduce alcohol consumption (Sanchez-Craig and Wilkinson, 1986/1987; Sanchez-Craig et al., 1987;
|
From page 81... ...
A plausible but still experimental relapse prevention strategy is cue exposure, in which the goal is to diminish a drinker's responsivity to cues that may precipitate the desire to drink or relapse. Empirical support for the cue exposure approach is currently limited to case reports (Blakey and Baker, 1980)
|
From page 82... ...
Group therapy as a distinct singular treatment is rare. As with individual psychotherapy, group therapy is offered in concert with alcohol education, referral to Alcoholics Anonymous, and additional supportive activities.
|
From page 83... ...
(Steinglass, 1979a) ; group therapy for married couples in which one or both spouses has alcohol problems; intensive three- to seven-day family intervention programs as part of fixed-length Minnesota model primary rehabilitation programs (Laundergan and Williams, 1979~; day treatment for marital couples (McCrady et al., 1986~; Al-Anon; family education; and the involvement of the multigeneration family in a series of therapy sessions.
|
From page 84... ...
It has developed a definition of treatment that can encompass all efforts to reduce alcohol consumption by persons who experience problems surrounding such consumption, as well as the additional supportive services required to prevent relapse and a return to destructive alcohol use. The committee's definition incorporates those activities that are currently labeled intervention as well as those labeled treatment and rehabilitation: Treatment refers to the broad range of services, including identircafion,brief intervention, assessment, diagnosis, counseling, medicalservices, psychiatric services, psychological services, social services, and follow-up, for persons with alcoholproblems.
|
From page 85... ...
Supportive services are required if relapse is to be avoided and continued sobriety and recovery is to be maintained by individuals who may have few personal and social resources and who are experiencing very severe physical, vocational, family, legal, or emotional problems surrounding their use of alcohol. The extent of the person's dysfunction in other key life areas (e.g., employment, physical health, emotional health, marital and family relations)
|
From page 86... ...
There have been a number of prior efforts to develop classifications of treatment programs for evaluating and funding treatment from a national perspective. These efforts have used such variables as treatment philosophy, settings, and modalities, but there has been no acceptance of a uniform classification.
|
From page 87... ...
1984. Classification of Alcoholism Treatment Settings.
|
From page 88... ...
1982. Evaluation of alcoholism treatment programs.
|
From page 89... ...
1977. Cost-benefit Study of State Hospital Drug and Alcohol Treatment Programs.
|
From page 90... ...
Mee-Lee, 1987a. The Cleveland Admission, Discharge, and Transfer Criteria: Model for Chemical Dependency Treatment Programs.
|
From page 91... ...
Pp. 63-103 in Future Directions in Alcohol Abuse Treatment Research, B
|
From page 92... ...
1982. Easy Does It: Alcoholism Treatment Outcomes, Hazelden and the Minnesota Model.
|
From page 93... ...
1986/1987. Bases for the use of abstinence as a goal in the treatment of alcohol abusers.
|
From page 94... ...
1974. Role of detoxification centers in alcoholism treatment.
|
From page 95... ...
Prepared for the IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse, July. Rubington, E..
|
From page 96... ...
Rockville, Md.: National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism.
|
From page 97... ...
1978. Alcoholism Treatment Effectiveness: An Outcome Study of New York State Operated Rehabilitation Units.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.