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3 What Is Trealment?
Just as it is necessary to clarify what is being treated in the realm of alcohol
problems, it is also important to review and crystallize what is meant by treatment because
there are many differing definitions. In most research studies, no single definition is
offered; instead, one often finds a series of procedures or a specific program and setting
being described and "evaluated." At other times, a rather complex and all-embracing
definition is presented. As a result, there are arguments and controversy about what
constitutes treatment for alcohol problems and who needs such treatment.
Is Alcoholics Anonymous a form of treatment? Are minor tranquilizers, when
prescribed for anxiety reduction after detoxification is completed, treatment or symptom
substitution? 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? Is family therapy a required element of the treatment
of alcohol problems? Is education and counseling for incipient problem drinkers who have
been arrested for a drinking-and-driving offense treatment?
Sometimes treatment is defined by what is reimbursable under a third-party
payment plan. This definition, however, does not so much answer the question as raise
alternative questions. Are biofeedback and stress management training for college students
who are drinking excessively at weekend fraternity parties reimbursable treatment
procedures under private health insurance? Is individual psychotherapy conducted by a
certified alcoholism counselor in a private-practice setting a reimbursable service? Is
chemical aversion therapy a safe and effective treatment for alcohol problems that should
be reimbursed under Medicare and private health insurance? Is Antabuse monitoring by
a certified alcoholism counselor working in a state-licensed outpatient clinic a treatment
for which private health insurance or the state alcoholism authority, or both, should provide
reimbursement? Is social model detoxification in a freestanding facility a form of treatment
for which Medicare should provide reimbursement?
Much of the argument surrounding this issue appears to reflect a failure to agree
on the definition of treatment for alcohol problems and on the active ingredients of the
treatment process (Moos and Finney, 1987/1988; Filstead, 1988a,b; IOM, 1989~. Consider
the following definitions, which have been offered in federal government reports over the
years:
"Treatment" means the broad range of emergency, outpatient, intermediate,
and inpatient services and care, including diagnostic evaluation, medical,
psychiatric, psychological, and social service care, vocational rehabilitation
and career counseling, which may be extended to alcoholic and intoxicated
persons. (U.S. Department of Health, Education, and Welfare
[USDHEW1, 1971:106)
Treatment/Treatment Services-The broad range of planned and continuing
services, including diagnostic assessment, counseling, medical, psychiatric,
psychological, and social service care for alcohol-related dysfunction, that
may be extended to program patients and influence the behavior of such
individuals toward identified goals and objectives. (Bast, 1984:11)
Alcohol treatment refers to the broad range of services, including
diagnostic assessment, counseling, medical, psychiatric, psychological, and
42
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WHAT IS TREATMENT
social services care for clients or patients with alcohol-related problems.
Treatment activities involve intervention after the development and
manifestation of alcohol abuse and alcoholism in order to arrest or reverse
their progress, or to prevent illness or death from associated medical
conditions . . . Treatment is essentially composed of two elements, (1) the
therapeutic procedure, i.e., a specific set of protocols and activities, and
(2) the therapeutic process, i.e., the milieu, setting, and interpersonal
context in which a procedure can be implemented for optimal success.
Treatment is a complex, interpersonal admixture of procedures and
processes. (U.S. Department of Health and Human Services [USDHHS],
1986:42)
43
The first definition given above was included in the Uniform Alcoholism and
Intoxication Treatment Act and as such became the basis for the definitions adopted by
state licensure and national accreditation bodies, thus setting the broad parameters that
underlie existing treatment and financing efforts. The Uniform Act had as its focus
decriminalization of public drunkenness and destigmatization of all persons with alcohol
problems (Plaut, 1967; Grad et al., 1971; Finn, 1985~. Its definition was to a large extent
based on the image of the typical alcoholic as the indigent, socially deteriorated public
inebriate who required extensive psychological and social support services along with
treatment of physical disabilities and direct treatment of the alcohol problem. This image
was embodied in the original legislation and in resource development carried out by the
federal government and the states.
The breadth of the various ~official" definitions of treatment for alcohol problems
reflects the importance that has been placed on including within the treatment process
additional supportive activities (e.g., vocational counseling, family therapy). Thus, the
definitions reflect the professional judgment that the treatment of alcohol problems cannot
be limited only to those direct activities that are designed to reduce alcohol consumption.
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~. The extent of the person's dysfunction
in other key life areas (e.g., employment, physical health, emotional health, marital and
family relations) determines the breadth of the treatment response required (Pattison et al.,
1977; Costello, 1980, 1982; Longabaugh and Beattie, 1985; Kissin and Hansen, 1985;
Sanchez-Craig, 1988; see also Kissin, 1977a,b; Armor et al., 1978; Brown University Center
for Alcohol Studies, 1985; Pattison, 1985~.
The second and third definitions given earlier (Bast, 1984; USDHHS, 1986) are
derivative of the Uniform Act definition and reflect the variety of treatment services that
have been supported by federal and state categorical funding in the early years of the
struggle to establish the treatment of alcohol problems as a distinct, legitimate activity
(Chafetz, 1976; Booz-Allen and Hamilton, Inc., 1978; Anderson, 1981; J. Lewis, 1982;
Weisman, 1988~. To a certain extent, federal and state governments have supported this
wide array of approaches to treatment because of differing theories about the causes of
alcohol problems. As Saxe and colleagues (1983:4) note: The treatments for alcoholism
are diverse, in part because experts have different views about the causes of alcoholism.
At least three major views of the etiology of alcoholism can be identified: medical,
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44
BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
psychological, and sociocultural. Treatments are generally based on one or a combination
of these views."
There has been a continuing effort not only to define the treatment of alcohol
problems as a primary condition (i.e., not a symptom of underlying psychopathology) but
also to develop a separate, nonpsychiatric specialist system of treatment resources. The
specialty programs directly treat the primary condition (Anderson, 1981; Weisman, 1988;
see Chapters 4 and 7~. The emphasis has been on creating a specialized continuum of care
that can assist individuals in dealing with the complex set of biological, psychological, and
sociocultural forces that create and maintain problem drinking behavior. As Glasscote
and colleagues (1967:13) have stated:
[I]t is abundantly clear that no single treatment approach or method has
been demonstrated to be superior to all others. Although numerous kinds
of therapy and intervention appear to have been effective with various
kinds of problem drinkers, the process of matching patient and treatment
method is not yet highly developed. There is an urgent need for continued
experimentation for modifying and improving existing treatment methods,
for developing new ones and for careful and well designed evaluative
studies. Most of the facilities that provide services to alcoholics have
made little if any attempt to determine the effectiveness of the total
program or its components.
These observations remain appropriate today. Treatment for alcohol problems, as
described in many of the studies and practice settings that have been reviewed for this
report, has been found to be just such an unspecified admixture of medical, psychological,
and sociocultural approaches. Research that organizes and evaluates the components of
treatment in a systematic fashion is only now beginning to be carried out (Saxe et al.,
1983; Walsh et al, 1986; Moos and Finney, 1987/1988; Filstead, 1988a,b; Holder et al., 1988;
IOM, 1989; T. McLellan, Philadelphia VA Medical Center, personal communication, May
25, 1989~. This committee's emphases on heterogeneity in etiology, presentation, and
course and on the need for individualized comprehensive treatment are not new
developments. 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. Research data are available on the effectiveness of "treatments" or
Interventions that cover a broad spectrum: from brief, one-session outpatient treatment
episodes for married, socially stable adult males in which the intervention is information
about the hazards of continuing to drink excessively and advice on how to control drinking
given by a physician or nurse (e.g., Edwards et al., 1977; Edwards, 1987) to months-long
hospital and residential stays that remove the affected person from the stresses and
seductions of an environment in which alcohol is easily available (e.g., Wallerstein, 1956,
1957; Blumberg et al., 1973~. Given this range, it has become customary to distinguish
between intervention and treatment when reviewing research and discussing available
services. Intervention is generally discussed in connection with primary prevention; a
prominent example of this approach is the most recent report on alcohol and health
submitted to Congress by the secretary of health and human services (USDHHS, 1987b).
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WHAT IS TREATMENT?
45
However, the term intervention has come to have two distinct meanings in the
treatment of alcohol problems in addition to its usual meaning in medicine and education
(i.e., an activity designed to moditr a condition). First, intervention is used to describe a
specific technique for confronting persons who are thought to have problems around their
use of alcohol and to motivate them to enter treatment (Johnson, 1980, 1986; Beyer and
Trice, 1982; Trice and Beyer, 1984; see Appendix D). As a technique used to bring people
into treatment, intervention involves nonjudgemental confrontation by family, friends, or
coworkers to break down an individual's rationalization and denial of the problems related
to excessive drinking (Blume, 1982~.
Second, intervention may be used to describe case finding and treatment of
"early-stage" problem drinkers, as noted by Cohen (1982:127~:
Early intervention consists of the identification of persons or groups whose
drinking behavior places them at risk and of persons in the early stages of
destructive drinking practices. It includes their involvement in corrective
learning and emotional experiences designed to help them develop
abstinence or more benign drinking patterns.
In this use of the term, early intervention is identified with secondary prevention,
and treatment is identified with tertiary prevention. The distinction is made primarily on
the basis of the target population, and secondarily on the goal chosen (abstinence or
controlled drinking), rather than on the basis of the activity that is actually performed.
Thus, intervention is described as being aimed at the "early-stage drinker" or less impaired
youthful drinker; treatment and rehabilitation are described as being directed toward "those
with established disabling, psychosocial disordersn:
Early intervention is conceptualized as the equivalent of secondary
prevention, the attempted reversal of the early stages of dysfunctional
drinking by individuals or homogeneous groups at risk. Secondary
prevention contrasts with primary prevention, i.e., the educational
approaches that attempt to reinforce healthful drinking attitudes especially,
but not exclusively among youths. Tertiary prevention consists of the
formal treatment and rehabilitation measures for those with established
disabling, psychosocial disorders. (Cohen, 1982:128)
Intervention activities are those that seek to detect alcohol-related
problems in their early stages and to intervene in such problems in such
a way as to arrest their progression .... 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.
(USDHHS, 1986:69)
It is important to distinguish between intervention activities and primary prevention
activities, which are aimed at those persons, whether abstainers or social drinkers, for
whom no alcohol-related problems have as yet been identified by themselves or by others.
Although sometimes labeled as early intervention, primary prevention more accurately
describes those specific activities that are aimed at persons who are not engaged in risky
or problematic drinking but who are designated as high risk because of such factors as a
family history of alcohol problems or childhood behavior problems. Secondary prevention
activities~ctivities that could more accurately be labeled Early interventions- involve the
identification of individuals who are drinking in a risky fashion and are beginning to
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46
BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
experience problems and symptoms. Actually, however, in view of the heterogeneity of
course discussed in the previous chapter, the designation "early is inappropriate. Many
persons so identified will not progress to more serious problems although some will (see
Chapter 6~. Examples of "early intervention" (secondary prevention activities) are
counseling heavy drinkers among college students (Marlatt, 1988a) or counseling patients
who are receiving medical treatment for alcohol-related physical illnesses or injuries (D.
C. Lewis and Gordon, 1983; Williams et al., 1985~.
There are many organizational entities in this country that sponsor and conduct
early intervention programs-social service agencies, drinking-driver programs, student
assistance programs, employee assistance programs, to name a few. It has been customary,
however, to view these locales and activities as intervention programs rather than
treatment; they are considered to be separate from the overall treatment system and
engaged in performing only referral and case monitoring (e.g., Saxe et al., 1983; USDHHS,
1987b), even though many also provide counseling and education. The committee considers
it an error to continue to omit these resources from consideration as elements of the continuum
of treatment services that should be available in each community to all persons who need them.
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) (see Chapter 9~.
The most direct and simple definition of intervention and treatment for alcohol
problems is "any activity that is directed toward changing a person's drinking behavior and
reducing their alcohol consumption. Treatment and intervention are both aimed at
changing the person's drinking behavior after a problem has been identified. Moreover,
both intervention and treatment generally involve additional activities that are designed
to alleviate other physical, psychological, and social problems as well as the conditions that
are assumed to cause or maintain the hazardous level of drinking.
Thus, activities that previously were classified separately as either intervention or
as treatment are included in the definition of treatment used in this report. The
committee clearly identifies and distinguishes any use of the term intervention to describe
the confrontational technique for motivating persons to seek treatment. At all other times,
intervention is used synonymously with treatment.
To guide its deliberations and recommendations, the committee has adopted the
following definition of treatment, which builds on the definitions reviewed earlier in the
report and incorporates both intervention and treatment:
Treatment refers to the broad range of services, including identification, brief
intervention, assessment, diagnosis, counseling, medical services, psychiatric
services, psychological services, social services, and follow-up, for persons with
alcohol problems. The overall goal of treatment is to reduce or eliminate the use
of alcohol as a contributing factor to physical, psychological, and social
dysfunction and to arrest, retard, or reverse the progress of any associated
problems.
The committee has formulated this expanded definition of treatment because it
agrees with those who have suggested that efforts to treat alcohol problems in this country
have been too narrowly focused on those persons with the most severe problems (see
Chapter 9~. The guiding principle it has espoused is that all of those individuals who are
identified as having a problem around their use of alcohol should receive some assistance
with their problems. The traditional approach to the management of alcohol problems has
often been the so-called Minnesota model of treatment (discussed later in this chapter),
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WHAT IS TREATMENT?
47
which focuses on the smaller number of individuals who show major symptoms of alcohol
dependence, physical disability, and psychosocial dysfunction. The committee favors a
broader approach that also deals with the much larger group of individuals who have
engaged in excessive\drinking and experienced some negative consequences (e.g., Skinner,
1985, 1988; Babor et al., 1986; Skinner and Holt, 1987; IOM, 1989~. This approach will
include the use of sites that provide brief interventions and brief therapy for persons with
low or moderate levels of alcohol problems. The successful utilization of brief
interventions will require changes in our conceptualization of the treatment system as well
as additional training in the conduct of brief interventions for workers in the specialty
alcohol problems treatment sector as well as in the general medical and social services
sectors (see Section III).
Other countries have developed similar strategies, some of which are described in
Appendix C. The effort to expand treatment availability in France is described by Babor
and coworkers (1983~. During the 1970s, the French developed a national network of
outpatient clinics to provide secondary prevention, in the form of early intervention services
to Habitual excessive drinkers who were to be identified through screening in various
industrial, legal, and health care settings. 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. Thus, a person is told to reduce drinking to the
amount he or she can tolerate without risk.
Another example of the development of an expanded network of services is the
methodology used by drinking-driver programs (see Chapter 16~. This approach identifies
persons arrested for a driving-while-impaired (DWI) offense and assigns them to an
education (intervention) or treatment experience on the basis of a screening that
categorizes individuals as social drinkers, incipient problem drinkers, or problem drinkers.
The military, which initially modeled its approach on that used by drinking-driver programs,
uses a similar methodology to assign individuals to education, outpatient counseling, or
inpatient treatment, (Borthwick, 1977; Armor et al., 1978; Zuska, 1978; Orvis et al., 1981~.
The approaches of all these programs are based on the view that alcohol problems must
be broadly addressed within an expanded treatment context.
Defining the Expanded Continuum of Care
Given the complexities of dealing with the wide range of medical, psychological,
and social difficulties presented by persons with alcohol problems, it has become customary
to speak of the need for a comprehensive continuum of available treatment services. This
continuum has become the operationalized definition of treatment for alcohol problems:
It is important that any funding mechanism for alcohol and drug services
cover a broad enough spectrum of services and service providers to insure
that the individual patients or clients are provided with a continuum of
care which is adequate and appropriate to their needs. Such care may
include a combination of inpatient hospital services, direct medical care,
residential care in various sheltered environments, counseling, job training
and placement assistance and aid in dealing with various life problems.
(Boche, 1975:3)
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48
BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
Similarly, Sections 1, 8, and 10~5) of the Uniform Alcoholism and Intoxication
Treatment Act explicitly called on the states to ensure that a continuum of coordinated
treatment services with reasonable geographic access was established within each state
(USDHEW, 1971~. The act emphasized a coordinated network of services within each
community to ensure that individuals would receive all the care appropriate to their needs
and not be denied access to services because of agency boundaries. The Uniform Act was
a major source for the treatment definitions presented earlier in this chapter; it is also the
major source for contemporary definitions of the components of the continuum of care and
the practices that currently represent the operational definition of treatment for alcohol
problems.
The continuum of care called for in the Uniform Act had four major elements:
(1) emergency treatment provided by a facility affiliated with or part of the medical service
of a general hospital; (2) inpatient treatment; (3) intermediate treatment; and (4)
outpatient and follow-up treatment. The description of the continuum was based on
observed practices and on contemporary efforts by several states to redefine what treatment
should be, based on research (Plaut, 1967) and surveys of existing programs (Glasscote,
1967; Grad et al., 1971~.
As the first element of the continuum, the Uniform Act used the concept of
emergency treatment in a hospital-related facility rather than the more popular
"detoxification center" (the latter was seen as stigmatizing persons with alcohol problems
by setting them apart from people with other illnesses or difficulties). These specialized
emergency services were to be readily available 24 hours a day to anyone who needed them;
they comprised medical services, social services, and appropriate diagnostic and referral
services. Inpatient treatment, the second element called for in the act, was to provide
24-hour care in a short-stay community hospital for that limited percentage of persons who
were thought to need to begin treatment in a restricted environment. Long-term hospital
inpatient services were considered to be inappropriate for persons with alcohol problems;
the short-term units were to be designed to facilitate the individual's return to his family
and the community or to other appropriate care services as rapidly as possible.
Intermediate treatment was the term used to refer to residential treatment that was
less than full time and that could be provided in a variety of community facilities (e.g.,
halfway houses, day or night hospitals, foster homes). Intermediate treatment settings, the
third element in the continuum of care, were seen as alternatives to hospital inpatient
settings and as extensions of initial inpatient services. The Uniform Act's final element,
outpatient and follow-up treatment, was to include the same wide range of treatment
services and modalities offered in the inpatient or intermediate service settings. The
difference was that these services would be offered in a wide variety of settings in the
community: for example, clinics, social centers, and even in the patient's own home
(USDHEW, 1971~.
In its 1986 report to Congress setting forth a comprehensive national plan to
combat alcohol abuse and alcoholism, the Department of Health and Human Services
(USDHHS) continued to discuss the need to provide and fully finance a "comprehensive
continuum of care approach" to the treatment of alcohol abuse and alcoholism. 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. (USDHHS, 1986:42)
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WHAT IS TREATMENT?
49
More recently, the continuum of care needed for the treatment of alcohol problems
has been described in another USDHHS report:
Although necessarily limited by cost effectiveness considerations, alcoholism
treatment has become increasingly multimodal and multidisciplinary. As
is generally recognized, a comprehensive system of services includes at least
the following: detoxification; inpatient rehabilitation; outpatient services
including clinic, day hospital, and partial hospital services; family treatment;
aftercare; residential or supervised living services; and sobering up services.
These categories of services are not mutually exclusive. (USDHHS,
1987b:124)
These slightly different descriptions show that the continuum has not been clearly
and consistently defined neither in terms of the elements that constitute it, the
combinations of elements required for particular groups within the population of persons
with alcohol problems (see, for example, Section IV), nor the sequence in which the
elements are required. The original Uniform Act description of the continuum focused on
the settings in which treatment took place, whereas the later descriptions called for
additional elements. Yet even in these key reports, many of the terms used to describe the
components are not defined. There is no clear statement in either the 1986 national plan
or the more recent report to Congress about how the continuum should be organized or
the desired relationship among the listed elements.
For example, in the most recent description of the continuum (USDHHS, 1987b),
the "sobering up services" element is introduced but without definition or discussion. Both
detoxification and sobering-up services are included as necessary elements, but no
distinction is made between them. Both are emergency treatment in terms of the original
Uniform Act definitions. The context of the report suggests that the inclusion of
sobering-up services as an essential element is to reflect the distinction that is now
commonly made among the two or more levels of detoxification care included by many of
the state alcoholism authorities in their planning and funding efforts.
In fact, the reference in the DHHS report is most likely drawn from a particular
element (now, no longer used) of the New York state continuum,~ the sobering-up station.
The sobering-up station was a particular form of the non-hospital-based, subacute, inpatient
detoxification unit and was initially introduced as a lower cost alternative to jail or to
expensive hospital-based detoxification for public inebriates (Zimberg, 1983~. 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~. This new model recognizes, as has been shown in
the research literature, that only a limited percentage of all persons who require
detoxification-and not just public inebriates need hospital-based services. Withdrawal for
the majority can be safely managed in a subacute, nonhospital social setting or in an
ambulatory medical model setting (O'Briant et al., 1973; Feldman et al., 1975; Whitfield et
al., 1978; DenHartog, 1982; Diesenhaus, 1982; Alterman et al., 1988; Hayashida et al., 1989;
Klerman, 1989~.
Another example of the lack of agreement on definitions among the various
continua are the descriptions of a "family programs or "family treatment." Again, it is not
clear what is meant. In the alcohol problems field, family therapy, in common with other
treatment modalities, is considered appropriate for some but not necessarily all persons in
treatment (McCrady, 1988~. In addition, family therapy may constitute different activities
in different programs or settings. The importance of the family in supporting recovery (i.e.,
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so
BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
changing drinking behavior) is recognized; yet there is little research on the effectiveness
of the various techniques or structured programs with particular kinds of persons with
alcohol problems the various subgroups (McCrady, 1988~. Looking beyond settings in
defining the desired elements of the continuum of care is of value, but there is not enough
evidence available to single out specific treatment modalities as appropriate for inclusion.
Yet this is exactly what has occurred in a number of definitions of the ideal
continuum of care. In addition, these descriptions tend to condense and confuse the
settings in which treatment takes place, the procedures or modalities that are used, the
stages or phases of treatment that are offered, and the philosophical model that underlies
a given treatment approach. The descriptions also do not sufficiently recognize that
different subgroups will require different elements in combination to sufficiently address
their alcohol problems. This imprecision is one of the factors that creates tensions
between providers, regulators, funders, and policymakers regarding the resources that are
needed and the proportions of treatment costs that should be financed either through
public or private third-party payment.
That the federal government continues to view the concept of a continuum of care
as important, however, can be seen in several of the recommendations made in the 1986
national plan proposed by the Department of Health and Human Services:
States and the private sector should develop a continuum of care based on
an assessment of need which accurately reflects age, ethnicity, sex, service
needs and other significant variables based on appropriate State and local
level data. (USDHHS, 1986:47)
Third party payers should selectively expand financing throughout the
continuum of care, thereby increasing the availability of treatment in a
variety of settings. (p. 46)
Public and private treatment programs should improve the match between
client and treatment by evaluating diagnostic techniques and the continuum
of care that is provided. (p. 50)
In keeping with this view, each state has defined its own continuum of care, some
(e.g., New York, Colorado, Indiana) very consciously tying the elements together to reflect
the stages or functions of treatment (in part to serve planning, funding, and evaluation
purposes). Others (e.g., California, Minnesota) continue to view the components more as
distinct entities. Some states include identification and intervention services in their
treatment continuum; others do not. 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. Yet
consistency is lacking even in the federal arena; thus the definitions are not consistent from
state to state, agency to agency or from survey to survey (Kusserow, 1989; Lewin/ICF,
1989a), a limitation that prevents the development of a comprehensive national approach.
If progress is to be made in defining treatment for alcohol problems, the elements
of the continuum of care that constitutes such treatment must be specified. In addition,
agreement must be reached on how those elements are defined and sequenced and how
they can best be used in matching various subgroups of persons with alcohol problems to
an appropriate series of interventions. Because there are still no widely accepted models
for describing either the course of treatment and recovery for persons with alcohol
problems or the settings in which each stage of that course can be most reasonably and
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WHAT IS TREATMENT?
51
least expensively accomplished, the committee has provided a preliminary framework for
a taxonomy of treatment elements as a starting point for defining the expanded continuum
of care.
Defining the Elements of Treatment in the Continuum of Care
In the attempts that have been made to describe the continuum of care needed for
the treatment of alcohol problems, there appears to have been some confusion among its
various elements: the philosophy or orientation of treatment, the stages of treatment, the
settings in which treatment takes place, the levels of care required by persons of varying
clinical statuses, the modalities to be used to decrease or eliminate alcohol consumption,
and the supportive services that are required by some individuals with extensive physical,
psychological, or social problems. To organize systematically the elements that should
make up the continuum of care, the committee proposes to employ a multidimensional
framework that distinguishes among treatment philosophy and orientation, treatment stage,
and treatment setting and level of care. This approach separates the specific treatment
modalities and supportive services that are used from the environmental context in which
they are applied (USDHHS, 1981, 1987b). In addition, the framework can serve multiple
purposes. Among them is its potential for organizing the studies that are necessary to
determine how best to match an individual with appropriate treatment. The framework
also provides a structure for analyzing the variety of placement methods that have recently
been introduced (Weedman, 1987; Hoffmann et al., 1987a).
Treatment Philosophy or Orientation
A model for treatment consists of a certain perspective on or orientation toward
the etiology of alcohol problems that in turn specifies the preferred methods of
intervention and suggests expected outcomes (Armor et al., 1978~. 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~. Three major orientations have been identified as providing the
rationale for the differing approaches to the treatment of alcohol problems: the
physiological, the psychological, and the sociocultural (Armor et al., 1978; Saxe et al.,
1983~.
Before proceeding with a discussion of these orientations, the committee would
emphasize that any description of these models constitutes an abstraction that does not
necessarily describe current practice. Nevertheless, the models have historical value in that
they inform us about the development of contemporary approaches-for example, the
evolving biopsychosocial model that is now endorsed by many practitioners.
The physiological or biological perspective, which underpins what is generally
known as the medical model of treatment, often considers "alcoholism" to be a progressive
disease that is caused by physiological malfunctioning and that requires treatment by or
under the direct supervision of a physician. Genetic risk factors are seen as important in
the etiology of the disease. Physiological treatment strategies focus on the person with
severe alcohol problems as the unit of treatment and may incorporate the use of
pharmacotherapy to produce change in the individual's drinking behavior. Medical
treatments include drugs to diminish anxiety and depression and such alcohol-sensitizing
agents as disulfiram (Antabuse).
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52
BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
The psychological perspective views alcohol problems as arising from motivational,
learning, or emotional dysfunctions in the person. Like the physiological approach,
psychological treatment strategies also focus on the individual and use psychotherapy or
behavior therapy to produce changes in drinking behavior. The psychological model can
also be further differentiated into variants that reflect differing theories about the etiology
of problem drinking behavior for example, whether alcohol problems are symptoms of
underlying psychopathology (intrapsychic conflicts) or are the results of social learning (the
behavioral model). Treatment based on psychoanalytically oriented dynamic theory is
another such variant. In this approach the individual psychotherapeutic relationship is seen
as the key element; adjunctive psychotherapies (e.g., group therapy, psychodrama,
occupational therapy) and supportive social rehabilitative services (Alcoholics Anonymous,
vocational counseling) help the individual to consolidate the gains he or she has made (e.g.,
Khantzian, 1981, 1985; Zimberg et al., 1985; Khantzian and Mack, 1989; Nace, 1987~.
The characteristic structure of a psychological model treatment regimen is a course
of intensive psychotherapy sessions (either individual or group, or a combination of both)
over an extended period of time in either a private practice or clinic setting. The primary
th~.r~ni.ct is usualiv a mental health professional (psychiatrist, clinical psychologist,
- ~-~r-~ ,
psychiatric social worker, psychiatric nurse, or clergyman). An antianxiety, antidepressant,
or antipsychotic medication is often used as an adjunctive therapy. Disulfiram is sometimes
used to provide external controls on drinking until the individual can develop internal
controls. However, the stress here is on the adjunctive or secondary nature of these
psychopharmacological approaches. Family therapy may also be used. Other strategies
include blood-alcohol-level discrimination training, biofeedback, and desensitization training.
One development of the past few years relating to the psychological treatment
model has been the increasing use of behavior therapy techniques, primarily by
psychologists (Poley et al., 1979; Lazarus, 1981; Marlatt and Gordon, 1985; Abrams and
Niaura, 1987; Marlatt et al., 1988~. The predominant approach is the social learning
model, which proposes that what a person believes about the effects of alcohol use on his
or her ability to cope with the demands of everyday life is a crucial determinant of how
involved with alcohol he or she will become. The social learning approach stresses the
important contribution of cultural norms, role models, and learned expectations about the
effects of alcohol in a given situation in determining drinking patterns. Social learning
theory views persons with deficits in general coping skills, such as the inability to manage
everyday stress, as vulnerable to the use of alcohol as an artificial method to modulate
their everyday functioning. Biological factors are seen to interact with these psychosocial
determinants, resulting in harmful drinking patterns (Abrams and Niaura, 1987~.
The sociocultural perspective, the third major treatment orientation, considers
alcohol problems to be the result of a lifelong socialization process in a particular social
and cultural milieu. Sociocultural treatment strategies focus on both the person and his
or her social and physical environment as the units of treatment; they use a variety of
techniques, including environmental restructuring, to change the individual's drinking
behavior by creating new social relationships. Sociocultural interventions include changing
the social environment by providing an alcohol-free living arrangement such as a halfway
house; active involvement in Alcoholics Anonymous (AA) or other mutual help groups;
social setting (as opposed to hospital-based) detoxification; and a social model of
rehabilitation. The sociocultural perspective emphasizes the importance of social groups
(e.g., church, family) in influencing not only the person's drinking behavior but also the
response to treatment and the potential for relapse. 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).
In recent years there have been a number of attempts to develop an integrative
model that could bring together these diverse orientations and perspectives. Such a model
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WHAT IS TREATMENT?
87
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Representative terms from entire chapter:
alcoholism treatment
