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What Addiction Treatment Really Needs

The field of addiction has to to get it together. This modest proposal offers five places to start, from individualizing treatment to professionalizing treaters.

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By Dr. A. Tom Horvath

11/19/12

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A groundbreaking report on the state of addiction treatment, “Addiction Medicine: Closing the Gap Between Science and Practice,” released earlier this year by the National Center on Addiction and Substance Abuse (CASA) at Columbia University, concluded that “the vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care.” And: “In many ways, America’s approach to addiction treatment today is similar to the state of medicine in the early 1900s.” This is a harsh comparison, but many clinicians agree that treatment for substance use disorders can be greatly improved.

So what should addiction treatment look like?

Having worked in this field for more than 25 years—as the founder of a treatment program in San Diego—I offer the following five guidelines for changing the treatment system in order to improve outcomes for people with drug and alcohol use disorders. 

1. Stop paying lip service to the idea of offering the full range of evidence-based interventions. Actually provide them.

In terms of psychotherapy, much clinical research over the past few decades supports a variety of treatments, including cognitive-behavioral therapy, motivational interviewing, 12-step facilitation therapy, and contingency management; these should be routinely incorporated into programming. Additionally, successful recovery programs should offer scientifically supported approaches involving loved ones of people with addictions, such as behavioral couples therapy and Community Reinforcement and Family Training (CRAFT). Finally, effective medications, such as the addiction drugs buprenorphine and naltrexone, should be available as part of an overall treatment plan as well as the continuing care plan.

Unfortunately, many treatment programs continue to use the 12 steps as the sole cornerstone while including other approaches only secondarily and neglecting still others altogether. And when these interventions are used, they’re often not employed as they were designed to be employed in the research studies that demonstrated their efficacy. Also, many addiction treatment programs still rely on interventions, such as lectures and films, that have been shown to be among the least effective recovery tools.

2. Trust that clients know something about themselves. Respect the need for, and value of, client choice.

It is well recognized that client motivation for participation in treatment is enhanced when clients are offered choices about their treatment goals and the types of services that connect with their inner experience. We know that involving clients actively in treatment planning increases treatment effectiveness. This is evidenced by the fact that the government agencies that license treatment programs require patient involvement and the patient’s signature on the treatment plan.

An individualized approach includes the client in a careful dialogue around the question of abstinence or moderation.

Too often, however, this is a rubber stamp that occurs after program staff have already designed the treatment plan, and it’s clear to clients that they’re “not in the driver’s seat.” They also frequently get the message that the desire to make choices is a sign that they’re suffering from a belief in their own “terminal uniqueness” (thinking they have special needs), and that the staff knows what’s best. In fact, every person with a substance use disorder does have unique needs and should be treated accordingly. Moreover, most clients have some sense of which strategies are likely to work best for them (and which aren’t). Another important part of client choice is having a say in who your primary counselor is; current evidence suggests that having a good relationship with one’s therapists or counselors is at least as important as working with professionals trained in the latest science-based approaches.

3. Offer truly individualized—not cookie cutter—treatment.

For too long, addiction treatment has been one-size-fits-all: in terms of not only what approaches are offered but also how they’re offered. For instance, while group treatment predominates at most residential and outpatient programs, many clients benefit from having more individual sessions than are commonly provided or even from treatment that is exclusively one-on-one.

Individualized treatment also involves a flexible policy about family visits and sessions. Unfortunately, many programs have, for example, a standard family ”psycho-educational program” during the third week of rehabilitation, or “family week.”

The full range of mutual help groups—including SMART Recovery, Women for Sobriety, Secular Organizations for Sobriety, LifeRing and Moderation Management—should be recommended, without prejudice, along with AA, NA and other 12-step groups. (This diversity needs to be accompanied by support in the form of research dollars—to study the efficacy of all mutual help groups, not just the 12 steps.) Currently, the vast majority of addiction treatment programs still involve the 12 steps. As a result, the many people who don’t connect with the 12 steps are left without a rudder. The limited evidence for alternative support groups suggests that involvement in any recovery group directly increases the amount of time participants maintain abstinence. But clients in treatment are rarely told about alternatives to AA and NA, and many treatment professionals are unfamiliar with them.

Critical to an individualized approach is including the client in a careful dialogue about the goals of treatment, particularly around the question of abstinence or moderation. As it is, very few facilities accept clients who are trying to moderate their use of chemicals—or who may recognize the need to quit but aren’t ready to do so—and many programs terminate those who use. A system that’s truly individualized meets clients “where they’re at.”

4. Be thoughtful about the length of treatment.

Our current treatment system focuses on people with the most severe substance use disorder and, even then, frequently waits for a crisis before intervening. Then, treatment is often applied according to a preconceived formula (for example, 28 days). People in the earliest stages of substance misuse—when treatment would be less expensive and more targeted—are often ignored. Those with mild impairment typically have nowhere to turn. Or they may be placed in a level of treatment that is too intensive for their needs.

A movement to professionalize addiction treatment exists, but we still have a long way to go.

Fortunately, academic and policy leaders in our field are making strides to solve this problem, but treatment programs could also accommodate people with less severe substance use disorders if they offered a wider range of approaches and services, from brief interventions to treatment that can be extended indefinitely. Since the growing consensus is that extended residential treatment is appropriate only for certain clients with the most severe substance use disorders and co-occurring problems, the system needs more and better outpatient options for extended care—ones that also provide quality group residential housing—and reimbursement systems that recognize the need for such long-term care.

5. Continue to professionalize the treatment of addictive disorders.

Substance use disorders deserve to be treated with the same rigor and vigor as we treat cancer. As the CASA report suggests, the training and credentialing of professionals in the addiction treatment field should be improved. And providers should be paid at a level commensurate with experts in other areas of healthcare.

Since most clients in the treatment system are likely to have comorbid conditions requiring mental health intervention, the minimum education for addiction treatment professionals should be a master’s degree. The CASA report also noted that some states don’t require any degree for becoming a credentialed addiction counselor while many require only a high school diploma, GED, or associate’s degree (only one state requires a master’s degree.)

A movement to professionalize addiction treatment exists, but we still have a long way to go. People with addictive disorders deserve to be treated by professionals with the skill to render the full range of science-based services.

Can we make these changes? Of course. Will we? If not, we will continue to pay the price in damaged lives and families. How long would change take? Perhaps as long as the recovery process takes for someone with a severe addiction. In both cases, the first step is enhancing motivation, by taking a close look at what might happen if change does not occur.

A. Tom Horvath, PhD, ABPP, is the founder and president of Practical Recovery in San Diego, an addiction treatment system including sober living, outpatient services and two residential treatment centers for alcohol and drug abuse; the president of SMART Recovery, an international nonprofit offering free, self-empowering, science-based mutual help groups for addiction recovery; a former president of the Society of Addiction Psychology (a division of the American Psychological Association); and the author of Sex, Drugs, Gambling & Chocolate: A Workbook for Overcoming Addictions.

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