Broadening the Base of Treatment for Alcohol Problems (1990) / Chapter Skim
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Chapter 4--Who provides treatment?
Chapter 4--Who provides treatment?
Pages 98-141
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From page 98... ...
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)
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From page 99... ...
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)
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From page 100... ...
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.
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From page 101... ...
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
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From page 102... ...
a mental health outpatient clinic, (3) a social model halfway house, and (4)
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From page 103... ...
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~.
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From page 104... ...
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)
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From page 105... ...
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)
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From page 106... ...
, 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.
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From page 107... ...
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.
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From page 108... ...
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)
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From page 109... ...
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~.
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From page 110... ...
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.
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From page 111... ...
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.
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From page 112... ...
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.
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From page 113... ...
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)
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From page 114... ...
. Detoxification centers-These programs provide subacute detoxification with minimal medical services provided onsite.
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From page 115... ...
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)
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From page 116... ...
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.
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From page 117... ...
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.
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From page 118... ...
By fiscal year 1986 the VA's 172 hospitals were operating 103 specialized ADTPs along with 51 drug dependence treatment programs (DDTPs)
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From page 119... ...
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~.
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From page 120... ...
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)
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From page 121... ...
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)
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From page 122... ...
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.
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From page 123... ...
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.
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From page 124... ...
. 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.
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From page 125... ...
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.
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From page 126... ...
. The three largest general categories of workers in treatment programs were counselors, nurses, and administrative and support staff.
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From page 127... ...
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~.
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From page 128... ...
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.
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From page 129... ...
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.
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From page 130... ...
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.
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From page 131... ...
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.
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From page 132... ...
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)
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From page 133... ...
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.
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From page 134... ...
Members Carry the Message into Treatment Facilities. New York: Alcoholics Anonymous World Services, Inc.
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From page 135... ...
Prepared for the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse. Washington, D.C.: National Association of State Alcohol and Drug Abuse Program Directors.
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From page 136... ...
1977. Cost-Benefit Study of State Hospital Drug and Alcohol Treatment Programs.
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From page 137... ...
1982. Easy Does It: Alcoholism Treatment Outcomes, Hazelden and the Minnesota Model.
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From page 138... ...
Prepared for the Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse., May. McGovern, T
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From page 139... ...
1989. Highlights from the 1987 National Drug and Alcoholism Treatment Unit Survey (NDATUS)
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From page 140... ...
1979. Alcoholics Anonymous as treatment and ideology.
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From page 141... ...
1987a. 1987 National Drug and Alcoholism Treatment Unit Survey: NDATUS Instruction Manual for States and Reporting Units.
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