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4 Who Provides Treatment?
Persons with alcohol problems receive care in a wide variety of health care, social
services, educational, corrections, and specialty mental health organizations, as well as in
organizations that specialize in treating alcohol and drug problems. Treatment is provided
by personnel from a variety of disciplines, including physicians, social workers, counselors,
and psychologists. This chapter provides an overview of the various types of providers and
personnel that make up the existing treatment services network and reviews the services
they provide within the continuum of care.
Describing the System to Treat Persons with Alcohol Problems
In recent years there has been tremendous expansion of both institutional and
community-based treatment programs within traditional agencies (e.g., general hospitals,
psychiatric hospitals, primary care clinics, family service agencies) and in nontraditional
facilities (e.g., social setting detoxification centers, public inebriate shelters, drinking-driver
programs, quarterway houses). There has also been a concerted effort to obtain increased
acceptance for the treatment of alcohol problems within the mainstream of health care
services; yet many of these newer agencies now treating persons with alcohol problems are
not located in traditional health care settings. These agencies reflect the historical
evolution of the field in this country in that the major impetus for expanded treatment
originated with Alcoholics Anonymous and the recovered persons who established
pioneering halfway houses (Pattison, 1974, 1977; D. J. Anderson, 1981; Saxe et al., 1983;
Weisner and Room, 1984; Weisner, 1986~.
There have been a number of efforts to describe the system that has evolved for
treating persons with alcohol problems, but the difficulties that surround this task have
prevented the formulation of an acceptable, comprehensive classification scheme that fully
incorporates the developments of the past 20 years. As discussed in the previous chapter,
the states, third-party payers, and key federal agencies use very different labels and
definitions for the elements in the continuum of care; one result of this variability is the
differing classification schemes used by funders to obtain data from treatment providers to
monitor utilization and appropriateness, to evaluate treatment effectiveness, and to develop
reimbursement strategies (Bayer, 1980; Wilson and Hartsock, 1981; Bast, 1984; Brown
University Center for Alcohol Studies, 1985; Institute for Health and Aging, 1986;
McAuliffe et al., 1988~.
Confronted with a similar lack of a uniform national and state approach for
describing relationships among the various service providers, D. ~ Regier and his
coworkers (1978) divided what they called the ode facto mental health services systems into
three major sectors: general health, other human services, and specialty mental health.
Their goal was to provide an initial systematic description of the services provided to
persons with behavioral and emotional problems in order to make analysis possible. This
framework can also be used to describe the ode facto systems that has developed to treat
persons with alcohol problems. Of most interest is Regier's view of the "specialty mental
health sector." He and his colleagues defined this sector as including those facilities and
practitioners that devoted themselves exclusively to the treatment of psychiatric disorders.
The specialty mental health sector included a wide range of facilities that provided inpatient
care, outpatient care, or both; these facilities ran the gamut from state and county
psychiatric mental hospitals, through halfway houses for the mentally ill, to college campus
mental health clinics.
98
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WHO PROVIDES TREATMENT?
99
Originally, treatment services for persons with alcohol and other drug problems
were considered to be part of the specialty mental health sector. Yet the Regier team in
its categorization excluded from the mental health specialty sector all facilities that
exclusively treated persons with alcohol problems; they also excluded those other
special-purpose facilities that treated drug abusers and the mentally retarded. (However,
persons with alcohol problems who were treated in mental health facilities were considered
to be part of the specialist sector.) The omission from the specialty mental health services
sector of specialty facilities treating only persons with alcohol problems reflected the
changes that were taking place in the organization and financing of treatment for mental
health, alcohol, and drug problems in the 1970s. In particular, this omission reflects the
insistence that alcohol problems were not always a symptom of mental illness but a disease
that required Primary treatment" within a specially designed continuum of care (Plaut,
1967; USDHEW, 1971; Grad et al., 1971; D. J. Anderson, 1981; Weisner and Room, 1984~.
This perspective influenced some of the states (e.g., California) to ston treating persons
with alcohol problems in state mental hospitals; however, other states (e.g., New York,
Minnesota, Colorado) developed specialty units within their state hospitals (Diesenhaus and
Booth, 1977; D. J. Anderson, 1981; Weisner, 1986~.
Over the past 20 years, two overlapping yet distinct specialty sectors have emerged:
the alcohol problems treatment sector and the drug abuse services system. Each sector
appears to have different structural and dynamic qualities that are shaped by ideology and
pragmatic survival needs (Weisner and Room, 1984; Cahalan, 1987~. If one applies the
framework developed by the Regier team (1978), then the specialist alcohol problems
treatment sector comprises those facilities and practitioners that treat only persons with
alcohol problems. In fact, what has emerged is a distinct network that embraces not only
facilities and practitioners but also funding agencies, regulatory agencies, interest and
advocacy groups, referral agencies, trade associations, and professional societies linked to
the treatment providers in the alcohol problems sector.
In addition to the independent facilities of the specialist alcohol problems sector,
provider organizations that belong to each of the other three sectors identified by the
Regier team (i.e., general health, other human services, specialty mental health) have also
developed specialized programs for treating alcohol problems. Currently, however, more
is known about the treatment of alcohol problems in the specialty sector than in these
other nonspecialist (i.e., non-alcohol specialty) sectors. He committee suggests that more
accurate descriptions arid studies of each of these sectors be developed as a first step toward
formulating recommendations for changes in practice and r-wing. These sectors are briefly
described in the paragraphs below.
Treatment of Alcohol Problems in the Nonspecialist Community Sectors
Following the definitions of Regier and colleagues (1978), the general health care
sector comprises all of those facilities and practitioners that offer treatment for alcohol
problems within their regular programs or practices. It includes the primary care
clinician-whether pediatrician, general practitioner, internist, nurse practitioner, physicians
assistant, or family practitioner-who attempts to care for a person who is concerned that
she or he may be drinking too much. In this instance, there may be physical problems that
bring the person to the attention of the care giver and that become the focus of the
treatment, rather than the drinking behavior itself. There is some evidence that the
majority of persons seen in this sector are women (Weisner, 1986~. The management of
the person with alcohol problems may consist of prescribing a minor tranquilizer (e.g.,
Valium) because the reason given for the excessive drinking is anxiety, brought on by stress
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100 BROADENING IXE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
at home or at work, or both, and providing supportive counseling. The proportion of
patients seen for this type of treatment is unknown.
As discussed in Chapter 9, estimates have been made and studies conducted in
various health clinics and other primary health care facilities of the number of persons in
treatment who are experiencing alcohol problems. However, these studies vary substantially
in the methodologies they use to determine the nature and severity of problems, and they
rarely review the treatment that was received. P. D. Cleary and coworkers (1988) reported
on a study that evaluated the ability of primary care physicians to identify and address their
patients' alcohol problems. Although physicians were aware of the problems in 77 percent
of the serious cases and in 36 percent of the less serious cases, they did not routinely
address them. The need to improve physician education in identifying and treating alcohol
problems is well recognized, and efforts are under way to provide such improvement (see
the discussion later in this chapter).
The general health sector also includes the short-term general hospital that has
no designated unit for detoxification or rehabilitation. It may be that more persons with
alcohol problems may be treated within this sector than are treated in the specialty sector
(Harwood et al., 1985; Davis, 1987~. Their treatment, however, is likely to be limited to
detoxification without rehabilitation or to treatment of the alcohol-related physical
problems. The general hospital without a designated detoxification or rehabilitation
program nevertheless can develop a screening and intervention program to increase the
number of persons with alcohol problems who are identified, counseled, and referred (if
necessary) to the appropriate specialist treatment (Lewis and Gordon, 1983; Williams et al.,
1985).
The Roger Williams General Hospital in Providence, Rhode Island, initiated such
a r~ro~ram. site visited bv members of the committee, in which a multidisciplinary
consultation team screens all admissions and assesses those that are found to have alcohol
or drug problems, or both. The team is able to identify approximately 10 percent of the
hospital's admissions as having alcohol or drug problems. The team then intervenes with
an assessment of the patient's problems, followed by advice and referral to specialist
treatment when indicated. Most of the persons identified by the screening procedures do
not have a previous alcohol problem diagnosis but did have a medical or social
complication directly related to alcohol intoxication or dependence. More than 80 percent
of those referred for further care followed through with their first treatment appointment,
usually in an ambulatory clinic (Lewis and Gordon, 1983; Williams et al., 1985~. lye
committee considers this type of program worthy of replication and rigorous evaluation. The New
York State Division of Alcoholism and Alcohol Abuse is currently providing grants to
eleven general hospitals to carry out such screening and interventions (New York State
Division of Alcoholism and Alcohol Abuse, 1989a,b). More efforts of this kind are needed.
Investigation of Regier's second sector, Other human services, finds similar
activities occurring. This sector embraces social services, correctional facilities and
programs, and educational agencies in which efforts are made to work with clients,
residents, inmates, students, and others who have problems with alcohol. Many correctional
institutions that have no organized program encourage volunteers from Alcoholics
Anonymous (AA) to come and work with their inmates, holding AA meetings within the
institution and attempting to link those who are released with a formal treatment program
or a sponsor, or both. Educational agencies may also provide services. Many school
districts have established student assistance programs (SAPs) to work with youth at who
are risk for or are already experiencing problems with alcohol and other drugs (G. L.
Anderson, 1979; Morehouse, 1984~. Some SAPs are linked to a district's health program;
others are linked to its school counseling program; still others may be freestanding.
The approaches used by various school districts may vary, but there is a common
theme that the treatment of alcohol problems is secondary to the agency's main educational
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WHO PROVIDES TREATMENT?
101
mission. Thus, the focus of most SAPs is identification and referral. The treatment offered
is most likely to be a brief intervention (e.g., rap groups, peer helper programs, education)
provided by guidance counselors, school psychologists, social workers, and, increasingly,
specialist substance abuse counselors (USDHHS, 1987b). Students who experience low or
moderate levels of alcohol problems are treated within the educational sector; those who
are identified as having more severe problems are referred to the alcohol problems
specialist sector, often through the juvenile justice system. The extent of the services
offered through SAPs is largely unknown, and for the most part, these programs have not
been rigorously evaluated.
The specialty mental health care sector, Regier's third category, includes those
mental health practitioners and facilities that offer treatment for alcohol problems within
their regular programs or practices. The sector includes the psychiatrist, psychologist,
psychiatric social worker, psychiatric nurse, and marriage and family counselor who attempts
to treat a person who has been referred either for a drinking problem or for another
psychiatric problem. In some instances there may be independent comorbid problems; in
others, one difficulty may have contributed to the other. Treatment is likely to consist of
prescribing an antidepressant, antianxiety, or antipsychotic drug and providing supportive
or insight oriented psychotherapy. As discussed in Chapter 3, the vehicle for providing
such psychotherapy (individual, group, or family) may vary with the therapist's discipline
and ideology.
This sector also comprises the public or private psychiatric hospital that has no
designated unit for withdrawal or rehabilitation but that admits persons with dual
psychiatric and alcohol problems or persons with alcohol problems only to a general
psychiatry ward. In addition, the specialty mental health care sector includes those
community mental health centers, psychiatric outpatient clinics, and sheltered workshops
that have no designated units but that do not exclude persons with alcohol problems.
The extent of the services provided to persons with alcohol problems in this sector is
largely unknown.
Treatment in the Specialist Alcohol Problems Sector
This sector includes those facilities, those units within larger facilities, and those
private practitioners that concentrate solely on the treatment of alcohol problems and that
provide organized programs of care for persons who require any or all of the treatment
stages identified in Chapter 3. The term facility is used rather than hospital because many
treatment services are now offered in settings that are not organized or licensed as general
or specialty hospitals or as other health care agencies (e.g., neighborhood health clinics).
Some of these facilities are freestanding residential programs, outpatient clinics, and day
programs that may be licensed by the state alcoholism authority or by the state social
services agency rather than by the state health facilities licensing agency. There is no
national standard for making these differentiations, a situation typical in other health care
areas as well. Rather, facility and program licensure is seen as a state regulatory function.
The specialist sector can be broken down further according to attributes that affect
organization and service delivery. The first grouping is those practitioners and
organizations that treat only persons with alcohol problems; the second is those
organizations and practitioners that have a specialty unit with a structured program which
is embedded within a larger organization or practice. Examples of components that
constitute the first grouping are the halfway house that admits only men who have
completed a hospital or residential primary rehabilitation program and who are determined
to be in need of continued support in a residential setting (i.e., extended care); the
outpatient clinic that provides alcohol education and intervention services to persons
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102 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
convicted of a drinking-related traffic offense; and a 58-bed specialty hospital that provides
primary rehabilitation to persons who have been detoxified and medically stabilized in a
general hospital. Examples of the second grouping are the 250-bed not-for-profit
community hospital that has a discrete 20-bed alcohol rehabilitation unit managed by a
national for-profit firm; the 100-bed private psychiatric hospital that has one 30-bed ward
offering a rehabilitation program and a second 30-bed unit offering a program dedicated
to the treatment of dual-diagnosis patients (i.e., those with coexisting psychiatric
syndromes); and the minimum security correctional institution that offers a three-week
primary rehabilitation day program for inmates that continue to reside in their cells or
dormitories.
Another categorization of the specialist sector that can be made is to group
practitioners and programs that treat only persons with alcohol problems and practitioners
and programs that treat persons with alcohol or other drug problems. In recent years, the
number of such combined programs has been increasing (Reed and Sanchez, 1986;
NIDA,~lAAA, 1989~. Recent national surveys of treatment facilities have found that most
persons are now being seen in combined alcohol and drug units, although this percentage
varies by setting and by state. Many states now have an overwhelming majority of
combined units reporting data on service delivery (e.g., Pennsylvania, Louisiana, Michigan).
Only a few states have a greater number of alcoholism-only units reporting (e.g., New York,
New Jersey, Rhode Island) (Butynski et al., 1987~. What is clear is that there has been a
definite increase in the number of combined programs and that many units that formerly
admitted only persons with alcohol problems now also admit drug abusers. What, if any,
impact this change has on treatment availability and accessibility for persons with alcohol
rather than drug problems remains to be determined.
The specialist sector can also be subdivided according to the type of population
that a given group of providers serves. The populations seen in different facilities may
differ on important sociodemographic and clinical variables (e.g., Kissin, 1977b; Kissin and
Hansen, 1985; Research Triangle Institute, 1985; Weisner, 1986~. An early study by
Pattison and colleagues (1978), which has been replicated a number of times, compared
the population characteristics at four different facilities: (1) an aversion conditioning
medical model hospital program, (2) a mental health outpatient clinic, (3) a social model
halfway house, and (4) a county police work rehabilitation center. The persons served in
each of the facilities were found to differ along a continuum of social competence; those
treated at the aversion conditioning hospital were the most socially competent and stable
and required fewer additional supportive services to achieve and maintain a positive
treatment outcome; those served in the police work rehabilitation program were the least
socially competent and stable and required many additional supportive services to achieve
and maintain a positive outcome. Some of the differences observed among the populations
in different facilities appeared to be caused by ideological considerations; others, by funding
source policies; and still others, by community pressures. Research on the relationship of
treatment ideology and organization to outcome is sorely lacking (e.g., Gilbert and
Cervantes, 1986, 1988; National Council on Alcoholism, 1987; Wallen, 1988~. These earlier
studies should be expanded and extende* the evolution of the specialist and nonspecialist alcohol
problems treatment sectors should be monitored to ensure that the various special populations that
might use these services are riot excluded from obtaining the resources they require (see Section
IV).
A number of other researchers have contributed to the discussion surrounding
specialist and nonspecialist sector treatment settings. Saxe and colleagues (1983) developed
an overview of treatment settings as part of their review of the cost-effectiveness of
treatment for alcohol problems. This effort was an important first step toward developing
a taxonomy that can be used to match persons with alcohol problems with the appropriate
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WHO PROVIDES TREATMENT?
103
type of care at each stage of recovery. The Saxe team described four types of settings:
inpatient, outpatient, intermediate, and other. The discussion below uses the Saxe
taxonomy to describe treatment settings found in the specialist alcohol problems treatment
sector.
Ir~pa~ie~ Treater Se~ir~gp; The inpatient setting in Saxe's taxonomy was further
divided into hospital and freestanding residential categories. Three types of hospital
settings were identified: general, psychiatric, and aversive conditioning. The general hospital
category was subdivided even further by the type of unit-detoxification or rehabilitation.
(The type of unit here corresponds to treatment stage as described in Chapter 3.) However,
Saxe and his coworkers did not specify types of units for the other inpatient settings or for
outpatient settings, a gap in their framework that should be addressed because setting and
stage of treatment are not necessarily linked.
An additional hospital category is the alcoholism or chemical dependency hospital,
which includes the aversion hospital noted by the Saxe team; 58 such hospitals were
identified in a recent American Hospital Association (1987) survey. The survey also
identified 874 general and other special hospitals that claimed distinct treatment units (15
percent of the total federal and nonfederal hospitals reporting) and 165 psychiatric hospitals
with separate units (31 percent of those reporting). The largest number of hospital units
were in California and Texas, although the states with the highest rates of beds per capita
were New Hampshire and North Dakota (see Chapter 7~.
Freestanding residential rehabilitation facilities, the second major type of inpatient
setting described by the Saxe team, may carry out rehabilitation only, detoxification only,
or a combination of both. Freestanding alcohol rehabilitation facilities vary in their
relationship to hospitals as described in the NIAAA-sponsored classification discussed in
Chapter 3 (Bast, 1984~. They can be a wholly owned unit located offsite or in a separate
building on the sponsoring general hospital's grounds. For example, California's Betty Ford
Center is housed in a separate building on the grounds of the sponsoring community
hospital; it is licensed as a specialty chemical dependency rehabilitation hospital, a category
unique to California (J. Schwarzlose, Betty Ford Center, personal communication,
December 18, 1987~. Freestanding rehabilitation facilities can also be independently owned
and maintain an agreement for backup by a hospital for detoxification and the treatment
of acute medical problems. The rehabilitation center can carry out detoxification in a
separate designated unit or as part of the rehabilitation unit.
Many of the states fund or operate freestanding detoxification centers that were
initially developed to replace the jails in which public inebriates were placed to sober up
(DenHartog, 1982; Diesenhaus, 1982; Finn, 1985~. These facilities may follow either the
medical model or the social model. Referral systems for detoxification vary from
community to community as a function of the resources available and the community's
level of acceptance of the social model or mixed medical and social model (see Chapter
7~. Most communities, however, have two parallel systems, a dichotomy based primarily
on whether the available funding sources recognize social model detoxification programs
as eligible providers. Such a division also reflects the continued identification of social
model centers with public inebriates, the homeless, and indigents (Diesenhaus, 1982; Sadd
and Young, 1986~.
In addition to their relationship to hospitals, freestanding alcohol detoxification
and rehabilitation facilities also vary in their licensing status from state to state; in some
states, freestanding facilities can now be licensed as specialty hospitals (e.g., California's
chemical dependency rehabilitation hospitals). Some notable freestanding alcohol treatment
centers (e.g., Hazelden in Minnesota; see Chapter 3) contain differentiated detoxification
and rehabilitation units and in some instances have multiple licenses for their acute care
units and their primary care units.
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04 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
Outpatient Settings In recent years, the hospital-based or freestanding specialist
outpatient clinic has become a major locus of treatment for alcohol problems. Outpatient
treatment settings include traditional outpatient clinics that offer individual, group, and
family therapy and clinics that offer f~xed-length day or evening rehabilitation programs.
These fixed-length primary care outpatient programs are often based on the traditional
Minnesota model inpatient programs. Harrison and Hoffmann (1986) described three such
programs as part of a study comparing the effectiveness of inpatient and outpatient primary
rehabilitation. Outpatients attended 20 primary treatment sessions in the evening following
work. Each session lasted approximately three hours and typically included a lecture and
one or two group therapy sessions. Family participation varied somewhat, ranging from
nightly participation in the program to one night per week involvement in family groups
and other activities. nAftercare~ followed the completion of the primary care phase of
treatment and consisted of weekly sessions for patients and Significant others" at the
programs along with referral to Alcoholics Anonymous. The three programs differed in the
amount of formal aftercare provided; one provided up to six months; another, a minimum
of six weeks; and the third, a minimum of eight weeks.
Intermediate Settings The day treatment or intermediate setting noted by the Saxe
team in its taxonomy has not been given sufficient attention by funders despite studies that
have shown it can be used effectively at each stage of treatment (Lebenlutt and Lebenluft,
1988~. As a result, there is no standard definition of day treatment, although it has been
differentiated from standard outpatient treatment. In general, day treatment has been
suggested as an alternate setting for primary rehabilitation, although there have been
instances in which its use has also been advocated for detoxification, extended care, and
relapse prevention (e.g., Kolodner, 1977; McLachlan and Stein, 1982~. In day treatment,
persons with alcohol problems participate in a structured program for most of the working
day (usually a minimum of four hours for a minimum of three days a week) for a set
number of weeks. This schedule contrasts with those of most outpatient programs, in
which the person generally attends one or two sessions a week for an open-ended period
of time.
It is not known how many day treatment programs are currently in existence across
the country. One reason for the paucity of information is that the day hospital category
has been included in the outpatient category in the most recent National Drug and Alcohol
Treatment Unit Survey (NDATUS; see the discussion later in this chapter) (USDHHS,
1987a). An earlier study by Frankel (1983) reported on a survey of 14 day treatment
programs that were identified using the definition contained in the 1980 NDATUS
(NIAAA, 1981~. The programs Frankel reviewed were selected from the 156 day care
programs identified in that survey and tended to fit the psychiatric variant of the medical
model (i.e., have a psychological orientation and use psychotropic medications in
treatment); indeed, 11 of the 14 programs used DSM-III concepts and criteria (see Chapter
2) for setting admission standards. The use of DSM-III diagnoses may have been related
to the programs' apparent focus on employed adults with health insurance. (Many publicly
funded social model specialty treatment programs that receive categorical state and block
grant funds through the state alcoholism agency do not use DSM-III or ICD-9 diagnoses
iLawrence Johnson and Associates, Inc., 1983; Lewin/lCF, 1988a,b]~. This informal survey
revealed a great deal of program variation in program duration, which ranged from 11 days
to 18 months. Shorter programs included an aftercare outpatient component; the specifics
of the various aftercare programs were not reviewed by Frankel.
All 14 programs used a structured Program schedule that included alcohol
~, ~
education through films and discussions, as well as ~nolv~oual, group, and family counseling.
All of the programs also required or expected participation in Alcoholics Anonymous. The
other components of the programs varied significantly, ranging from a highly behaviorally
oriented program to more traditional Minnesota model primary care approaches. A
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WHO PROVIDES TREATMENT?
105
number of the programs met at night in four-hour sessions so that the person in treatment
could continue working during the day.
Several of the programs reviewed by Frankel were day treatment programs that
were sponsored or operated by employee assistance programs (see the discussion under
"Other Treatment Settings" later in this chapter). One such effort was the United
Technologies Employee Assistance Program, which developed and operated its own day
treatment program as an alternative to costly hospital-based primary rehabilitation programs
and what it considered to be ineffective, one-session-per-week outpatient programs
(Bensinger and Pilkington, 1983; Frankel, 1983~. The program ran 5-l/2 days per week,
offering an intensive course of seminars, psychotherapy, and AA meetings at the treatment
facility (two per week) to selected employees who were identified and referred by EAP
counselors as individuals whose needs were appropriate for this level of rehabilitation care.
Two days per week in the program were designated as family days; significant family
members were encouraged to participate, and a weekly Al-Anon meeting was held at the
treatment facility. Clients and spouses were expected to attend additional outside AA or
Al-Anon meetings while in the program and to continue in an AA group once they had
been discharged. The planned "stay" was two weeks, but it could be shortened or
lengthened according to individual needs. For those needing detoxification and medical
treatment, coordinated services were available at an affiliated detoxification unit in a nearby
general hospital. Aftercare consisted of work site meetings with the EAP counselor as well
as participation in AA groups.
One of the great attractions of the day treatment concept, both for persons with
alcohol problems and, indeed, for any psychiatric and medical patients, is its lower cost
compared with inpatient treatment (whether in a hospital or in another residential setting).
Day treatment or day care has also been proposed as an alternative to long-term care in
a skilled or intermediate-level-care nursing home for the chronically physically and mentally
impaired and for the frail elderly. Those who advocate use of the day-care alternative have
developed similar formulations of the issues involved, whether the focus is treatment of the
person with alcohol problems, or treatment of the physically or mentally ill. Dibello and
colleagues (1982) suggested that psychiatric day-care programs, including those that serve
people with alcohol problems exclusively, be classified into four major types according to
which needs are served: (1) crisis support programs for individuals with acute phase
disability who exhibit dramatic and serious symptoms and who require stabilization services
to return to their presymptomatic state; (2) growth treatment programs for relatively
stabilized persons with residual dysfunction who require habilitation/rehabilitation services
to improve their interpersonal and vocational role performances; (3) maintenance-supportive
treatment programs for persons with chronic problems who are stabilized and who require
long term continuing care and support to prevent deterioration and relapse; and (4)
diagnostic programs for persons who require direct observation over a significant period
of time to identify problem areas and formulate a treatment plan.
The first three types of programs in the Dibello scheme are similar to the the
three major stages or phases (acute intervention, rehabilitation, and maintenance) in the
committee's model of the stages of treatment for alcohol problems described in Chapter
3. The fourth type, diagnostic programs, is also included (as a component of the
assessment phase, a necessary part of the continuum of care and the committee's treatment
stages model). The use of day care as a less expensive alternative to hospital care can be
justified for "selected" individuals who need crisis stabilization (acute intervention) and
growth treatment (rehabilitation). Day-care programs can also reduce costs by shortening
the length of hospital stays when they are used as a transition from hospitalization to
independent community living for patients who need maintenance-supportive care (extended
care and relapse prevention) in order to avoid relapse.
. .
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106 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
Some day treatment efforts have been directed toward a particular special
population (see Section IV). Zimberg (1974, 1983) described a pilot day-care program
targeted to the needs and lifestyle of the "black socioeconomically deprived alcoholic" as
part of a comprehensive program offering ambulatory and hospital detoxification, a halfway
house, medical treatment, and vocational counseling. However, neither this model nor any
of the other day treatment variants described above has been widely disseminated and
replicated or evaluated, despite several studies suggesting that, for undifferentiated groups
of persons needing treatment for alcohol problems, primary care in an intermediate, or
day-care, setting is just as effective as inpatient Drimarv care in a hospital or other tiptoe of
residential setting.
One such study that became an important basis for policy development was a
comparison of inpatient and outpatient treatment carried out on behalf of the Minnesota
Chemical Dependency Program Division (Harrison and Hoffmann, 1986~. Using a
quasi-experimental design (because clinical realities and pragmatic considerations precluded
the use of random assignment), this study contrasted four-week inpatient primary care at
two facilities with four week-outpatient primary care at three facilities. All five of the
programs reflected the Minnesota model of treatment and were organized around the
philosophy and 12-step recovery program of Alcoholics Anonymous. They were also
homogeneous in methods and intensity. Lectures and group sessions were the primary
components of the rehabilitation approach; the AA variant of the disease model of
chemical dependency was the source of the educational content of the lectures, films, and
discussions. Total abstinence from all mood-altering chemicals was the goal of treatment
for all five programs.
Harrison and Hoffmann found that there were no differences in outcome for
subjects in the two conditions who were matched for number and severity of their
alcohol-related symptoms and impairments. Despite some limitations as a result of
sampling restrictions, the study's findings were an important contribution to the policy
changes adopted by the Minnesota legislature in creating its consolidated funding strategy.
This approach, which is discussed in Chapters 18 and 20, uses a single method to match
persons to the appropriate level of care for treatment paid for with state-administered
funds.
Similarly, Longabaugh and colleagues (1980, 1983) reported on the results of a
study in which persons undergoing detoxification were randomly assigned to an inpatient
or an equivalent partial hospitalization primary rehabilitation experience. Day hospital
patients lived at home and commuted daily to the hospital to attend its Problem Drinker
Program (PDP) (McCrady et al., 1985~. Inpatients resided in one of the hospital's patient
care units and walked to the same program; inpatients also participated in other activities
in the unit's therapeutic program. The study found that persons treated in the partial
hospitalization program functioned as well or better than their inpatient counterparts on
all critical measures of treatment outcome.
The committee visited the program and found the PDP to be a highly structured,
behaviorally oriented approach that uses the principles of social learning as its underlying
theoretical basis. Like the majority of behavior therapy variants of the psychological model,
the PDP begins with a thorough assessment of the behavioral patterns associated with
drinking and with a functional analysis of the person's urges to drink and his or her
drinking episodes (i.e., behavioral chains). The program uses group sessions to teach
patients how to carry out the functional analysis and to set specific goals for behavioral
change. Educational sessions and materials deal with the negative consequences of unwise
alcohol consumption and common behavioral patterns that are associated with excessive
drinking. Volunteers who have overcome serious drinking problems serve as role models,
modeling specific behaviors that are designed to reduce drinking. Planned activities,
contingency contracting, and social skills training offer practice in carrying out alternative
--rid or
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WHO PROVIDES TREATMENT?
107
behaviors. Married patients participate in couples groups; in addition, a relatives workshop
focuses on reinforcing positive behavior, decreasing family protection of the patient's
drinking, and coping with relapses. When appropriate, meetings are held with employers
to establish specific contingencies (in terms of work consequences) that will result from
drinking and non-drinking behavior.
The PDP is an ongoing program that receives reimbursement from most insurers
but that has not been extensively replicated elsewhere despite its demonstration of potential
cost savings (McCrady et al., 1986~. The committee sees an expansion of intermediate care
programs such as the PDP as an important element in increasing treatment availability.
Efforts to replicate such programs are indicated but appear to require additional resources,
as well as, a series of clinical trials with various populations and unit locations, to persuade
practitioners and funders of their unique value. The combination of primary care, and
extended care when needed, and maintenance in the same program seems to be related to
successful outcome as shown in a number of studies and suggested by several researchers;
however, translation to clinical practice may require additional clinical trials as well as
modification of current financing mechanisms (McCrady et al., 1986~.
Often, halfway houses are also considered to be intermediate care settings. They
have most frequently been described as transitional residential living facilities for persons
who have completed primary treatment but require additional support and treatment to
maintain their initial gains (e.g., Rubington, 1974; Berman and Klein, 1977; Armor et al.,
1978; Orford and Velleman, 1982; Pattison, 1985~. In this sense, they tend to be used as
extended care for less socially competent persons who require additional support to achieve
and maintain a positive outcome. Confusion is created, however, because the same label
had been applied to facilities that also offer primary care services and to extended care and
maintenance services. New terms have been introduced to differentiate among the various
services offered by these facilities (e.g., quarterway homes, domiciliaries, alcohol-residences,
recovery homes).
Thus. there is no uniform definition among the states of the halfway house and
the services it offers. Some states view it solely as a setting that provides a supportive,
alcohol-free living environment; any ongoing formal treatment (extended care or
maintenance) must be delivered elsewhere. Other states require that halfway houses be
professionally staffed and provide formal treatment. Private and public health insurers
tend not to recognize halfway houses or recovery homes (the term used primarily in
California) as eligible providers, and they frequently do not provide coverage for primary
care, transitional care, extended care, and maintenance activities provided by these facilities
(see Chapter 18~. Again, studies are needed of the service profiles and outcomes associated
with different paths through the alcohol problems treatment system that will determine
the appropriate role of such facilities and the propriety of coverage for their activities.
Other Treatment Settings The committee has chosen to discuss under this rubric
several areas of treatment provision that cannot appropriately be subsumed under the
earlier treatment setting categories (although these areas may include elements or
components that characterize those settings). The treatment programs to be discussed
include those operated by the Salvation Army; self-help groups-in particular, Alcoholics
Anonymous; drinking driver programs; and employee assistance programs.
The treatment programs operated by the Salvation Army are one such example
of the complex residential treatment services that have evolved to provide a continuum of
care within one facility (Stoil, 1988~. Originally thought of as halfway houses, these
programs are a mixture of the social and medical models, although the Salvation Army
tends to see itself more as a social service sector agency with a medical unit than as a
specialty alcohol problems treatment sector agency. Its programs provide social support,
vocational rehabilitation, and medical services, along with primary treatment, to those
persons with alcohol problems who are seen as among the least socially competent and
~7
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108 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
stable and who have the poorest prognosis. It is estimated that the Salvation Army treats
more than 70,000 persons each year. Its Harbor Lights or Social Rehabilitation programs
serve primarily men (often skid row residents or homeless persons) who have few personal
or economic resources and for whom treatment must indude additional supportive services.
Salvation Army programs place a strong emphasis on vocational training and spiritual
counseling and are still often viewed as halfway houses because of their target population
and their emphasis on job placement and retention occurs concurrently with attempts to
modify drinking behavior through various modalities (e.g., AA meetings, monitored
They typically offer a longer term
ul~;rvenuan mat comprises an 1nltlal primary care phase and an extended care program.
Se1J-help groups Self-help groups, primarily Alcoholics Anonymous (AA), Al-Anon,
and Alateen, are a significant segment of the specialist sector. There are also several newer
groups, such as Women for Sobriety and Drink Watchers (see Appendix C), that offer an
alternative ideology and model of recovery. Although these groups are used by some
persons, but do not yet have the acceptance or the worldwide distribution currently enjoyed
by AA (J. Kirkpatrick, Women for Sobriety, personal communication, December 14, 1987~.
AA was founded in 1935 by Bill W., a New York stockbroker, and Dr. Bob, an
Akron surgeon, who met at Bill W.'s initiative to discuss their problems in abstaining from
drinking alcoholic beverages (Alcoholics Anonymous World Services, Inc., 1955, 1959~.
(Consistent with AA's tradition of anonymity, the literature does not use last names,
although Bill W. had participated quite publicly in the expansion of research, teaching
efforts, and treatment services. He testified before Congress in 1970 at the hearings held
by Senator Hughes regarding the need to develop a cohesive national policy and to
establish the National Institute on Alcohol Abuse and Alcoholism.) Al-Anon is a network
of similar self-help groups for the spouses of persons with alcohol problems; Alateen serves
the same function for their children (Ablon, 1982; Al-Anon, 1986; Cermak, 1989~.
AA has grown to be a worldwide organization while still maintaining its basic
structure and traditions (Leach and Norris, 1977; Kurtz, 1979; Alibrandi, 1982; Rudy, 1986~.
Indeed, the use of AA principles and techniques has become an integral part of the
majority of treatment programs in this country (Boscarino, 1980; Bradley, 1988~. AA is the
best-known alcohol problems treatment resource. and most lav~ersons consider it to he the
most useful (Robinson and Henrv. 19791.
Antabuse, alcohol education, group counseling).
_, ~ ~ . . , . <
-
~,
~O
~1 - -
, ~ ~
Belonging to AA demands participation in a program of recovery, called by the
organization "working the twelve steps." The twelve steps are guides to the process of
personal chance that is required to achieve sobriety. A program of recovery includes (a)
paruc~pa~ng In meetings in which members share the history of their problems caused by
drinking and their experiences in maintaining sobriety; (b) obtaining help and support from
other members in meeting the challenges that in the past have led to "slips" and a return
to drinking; and (c) finding an AA member who will serve as a sponsor and provide
guidance and help in times of crisis when the urge to return to drinking becomes
overwhelming. Members typically attend at least one meeting a week; new members are
encouraged to attend daily meetings Ninety meetings in 90 daysn). The AA program of
recovery and Its pn~osopny are described In a number of publications that are studied by
all members. The fundamental text is the book Alcoholics Anonymous, published by AA's
General Services Office (Jackson, 1988~.
From AA's inception, its members have viewed their problems with alcohol as
"alcoholism-an illness that prevents those afflicted with it from controlling their drinking.
In the organization's view "recovery" requires self-diagnosis and acceptance of the inability
to control drinking and its inevitable consequences: therefore. according ~o AA recovery
requires abstinence.
The individual AA group and the meetings it holds are of central importance to
the organization's functioning. Meetings have a common structure: one member is elected
_
~,
O I- )
~1 ~ 7 ~-- ~_ _ _ an, I,,,
OCR for page 131
WHO PROVIDES I'REATMENI?
131
skills that various medical disciplines should possess (e.g., pediatricians, internal medicine,
family medicine) and also to define the minimal knowledge and skills all physicians should
possess in diagnosis and referral for alcohol and other drug problems (Alcohol, Drug
Abuse, and Mental Health Administration, 1985~. It attracted medical leaders from
universities, national professional societies, and the Public Health Service and formed a
consensus that was the basis for a new federal contract program to develop and implement
model curricula for medical students and residents. As a result of these efforts, there is
now a clearer understanding of the curricular content needed (and the most effective
means of teaching this content) to develop the essential alcohol problems-related
knowledge and skills for all physicians across specialities and in particular for the
disciplines of pediatrics, family medicine, and internal medicine. In addition, contracts have
recently been awarded to schools of nursing to define that profession's teaching needs and
to develop a model nursing curriculum. NIAAA and NIDA have also launched a new
grant program that establishes a medical and nursing faculty fellows program to enlarge
and improve alcohol- and drug-related clinical training. All of these recent efforts by the
federal government are in response to a growing interest among the general public and
medical professionals concerning these training issues (Bowen and Sammons, 1988~.
Part of the renewed interest in medical training related to alcohol problems has
come from groups interested in primary care, including such national professional societies
as the Society of General Internal Medicine, the Society of Teachers of Family Medicine,
and the Ambulatory Pediatric Association. These organizations, which are committed to
providing quality primary care of common problems, recognize the pervasiveness and
heterogeneity of alcohol problems and the sorts of interventions that may be effective,
including the kind of brief advice and treatment discussed elsewhere in this report (see
Chapter 9~. These national professional societies have formed active task forces and have
joined with the American Medical Association as cosponsors of the annual AMERSA
national conference. All of these developments in medicine and nursing point to a new
breed of practitioner who will have received formal education about alcohol problems and
who will be able and willing to identify and treat alcohol problems or to refer individuals
for specialist treatment.
This new breed of practitioners will join the cadre of trained professionals-
physicians, nurses, counselors, social workers, and clinical psychologists-already at work
providing treatment for alcohol problems. Unfortunately, the dimensions of this cadre are
unclear because there is a serious lack of accurate, timely work force data at the national
level. This lack of data compromises efforts to plan for future training and professional
needs. Fundamental questions for each of the disciplines involved cannot be answered:
for example, the backgrounds and characteristics of persons working in the field, whether
they are working in the specialty alcohol problems treatment sector or in the related
primary health, corrections, education, mental health, or social services sectors; the nature
of their long-term career opportunities; and whether there is currently growth or
constriction in the number of specialized training programs. As a consequence, it is not
possible to formulate a forward-looking work force training policy.
Currently, there is no national group or agency charged with gathering work force
data and with formulating an appropriate policy on training and credentialing. During
the process of completing the report the committee learned that staffing information was
to be added to the NDATUS. This addition is a positive development but will only
provide data for the specially treatment sector. Such data needs also to be collected from
the nonspecialist sector. Recent federal legislation (the Anti-Drug Abuse Act of 1988)
gives the clinical training responsibility for counselors and health professionals to
ADAMHA's Office of Substance Abuse Prevention (OSAP), suggesting that there will be
a renewed federal interest and effort (Horizons Technology, Inc., 1988~. Under an
interagenc y agreement, OSAP will focus on the training of counselors and health
OCR for page 132
132 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
professionals already in the field, and NIAAA and NIDA will continue and expand their
efforts to educate health professionals at the the graduate school and continuing education
levels.
Given the lack of concerted, coordinated human resources planning and the
questions that continue to be raised about the roles each discipline should play in
delivering and in administering treatment for alcohol problems, there appears to be a need
to reestablish a untidied work force planning exhort. The first steps in such planning should
be accurate determinations of the staffing in existing specialist programs and the role or
roles currently played by each discipline.
Summary and Conclusions
Persons with alcohol problems receive care in a wide variety of generalist
organizations, as well as in organizations that specialize in treating alcohol problems. A
description of either the specialist service delivery system or the generalist system is
difficult because there has not yet been an acceptable comprehensive classification that
fully incorporates the developments of the last 20 years. One major development has been
the tremendous expansion of institutional and community-based treatment programs, both
within traditional agencies (e.g., general hospitals) and nontraditional agencies (e.g.,
freestanding social settin~oxification centers). There also appear to be an increasing
number of private practitioners working in the field of alcohol problems. Treatment is
provided by personnel from a variety of disciplines including physicians, social workers,
counselors, and psychologists. There have been redefinitions of the roles played by each
discipline in more traditional health care facilities, but, in all of the organized settings,
alcoholism counselors have become the major providers of treatment.
Even though there has been a major effort to obtain increased acceptance of the
treatment for alcohol problems as belonging within the mainstream of health care services,
many of these newer agencies are not in traditional health care settings and do not follow
what have become the established patterns of staffing and functioning. This variation has
contributed to problems in describing who is providing what kind of treatment to whom.
Some of the agencies focus on providing one type of care (e.g., social setting detoxification,
hospital-based rehabilitation]: others attempt to offer comprehensive health and social
---rig ~ 1 ~
services during all stages of treatment to a special population (e.g., tne Salvation Army,
Indian Health Service). The dominant historical influence on the field has been its origins
in the integration of Alcoholics Anonymous philosophy and professional concepts now
known as the Minnesota model and exemplified by the pioneering work at Willmar State
Hospital, the Hazelden Foundation, and the Yale Plan Clinics. Alcoholics Anonymous
itself continues as the best-known provider of support and treatment for alcohol problems.
Although is possible to draw a broad outline of the service delivery system for the
treatment of alcohol problems and to describe some of its components, it is not possible
to accurately identity who provides what types of treatment to whom because of the lack
of systematic surveys and studies. The evolving network of service providers (both
programs and personnel) and the relationship of provider characteristics to the availability,
conduct, and outcome of treatment have not been adequately described or studied (Gilbert
and Cervantes, 1988; Wallen, 1988~. An expanded research program is needed to investigate the
social ecology of the treatment system (Weisner and Room, 1984; Weisner, 1986~. In
developing its analysis of the treatment system, the committee has been hampered by the
lack of studies on a number of important topics: the impact of the organizational,
ideological, and financial characteristics of treatment providers; their interrelationships;
their relationships to referral sources; and the impact of various funding strategies on the
organization, utilization, and outcome of treatment. More research is needed; examples of
OCR for page 133
WHO PROVIDES TREATMENT?
~ 22
studies that should be replicated and expanded are (a) examination of the trends in the
profiles of offered services that are associated with ownership type (Yahr, 1988), (b)
examination of the utilization of different services by the various special population groups
(Gilbert and Cervantes, 1988), and (c) examination of trends in reimbursement sources for
different types of specialty programs (Creative Socio-Medics Corporation, 1981~.
Performing such studies will require surveys that are better designed and better conducted
than the major vehicle now available, the National Drug and Alcohol Treatment Unit
Survey.
Studies of service profiles and of the outcomes associated with different paths
through the treatment system are also needed. Specifically, research should investigate
the value of providing increased intermediate care (day-care) options at each stage of
treatment and of providing social model treatment. Private and public health insurance
tend not to recognize day-care programs, halfway houses, or recovery homes as eligible
providers, thus cutting off from coverage those persons needing such care. These programs
generally are a mixture of the social and medical models, offering social support, vocational
rehabilitation, and medical services along with primary treatment. 77ze committee sees an
Hanson of intermediate care programs as an important element in increasing treatment
availability and effecfiveness.
Any studies of the organizations in which treatment services are provided must also
analyze who performs the specific services. Human resources utilization in the treatment
of alcohol problems continues to be somewhat controversial. One of the major aspects of
this controversy is whether recovering persons, who in many cases have developed their
own programs outside the health care mainstream, should continue to fill the void left by
traditional health and mental health professionals in treating people with alcohol problems.
Along with the development of nontraditional treatment programs in the specialty sector,
there has been a shift in the usual alignment of staff roles and responsibilities that has not
yet been consolidated into a single approach to human resources planning, training, and
credentialing. Without a national policy or program for developing such an approach, each
state and involved discipline currently develop their own policies. The degree of activity
and the particular mechanisms used vary considerably among these bodies.
Given the lack of concerted, coordinated human resources planning and the
questions that continue to be raised about the roles each discipline should play in
delivering and administering treatment for alcohol problems, there appears to be a need
to reestablish a unified manpower planning effort. The first step in such planning is
accurate determinations of the staffing in existing specialist programs and of the role or
roles currently played by each discipline in programs in both the specialist and
nonspecialist sectors. Additional research is required to determine the nature and level of
treatment services being provided by each of the disciplines in the generalist health, social
services, education, and corrections sectors as well as in the specialist alcohol problem
treatment sector.
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Representative terms from entire chapter:
treatment programs
