My 2017 Wish List for Substance Use Disorder Treatment (Part II)
All of the items on Part 1 of my 2017 wish list had to do with treating individuals with substance use disorders the same way people diagnosed with other disorders or illnesses are treated by our health system. That is, it’s considered unethical or inappropriate to call them names or label them. We involve them in decision-making concerning their treatment – while not imposing goals on them. The standard is to provide them with access to the latest medications shown to be helpful for their conditions. And we continue to provide their care – even with they’re not fully compliant with recommendations.
My wish list continues as follows:
Wish #5 Stop coercing clients/patients and those in the criminal justice system to attend 12-step meetings as part of treatment, continuing care, and/or legal mandates.
Although research suggests that people who get involved in AA (the group to which almost all research funding concerning recovery groups has been devoted) have better outcomes than those who do not, drop out rates remain high over time. It’s just not the right fit for many people, and they are seldom told of alternatives. When it comes to legal mandates to attend 12-step meetings, multiple higher courts across the country have ruled this illegal unless also offered a secular alternative such as SMART Recovery or LifeRing Secular Recovery. Why? Because these courts view AA as a religious program and coercion to attend is considered a violation of first amendment rights. Unfortunately, little research is available on alternative support groups to AA. In an upcoming article, I’ll discuss a new study that provides support for encouraging clients to try different kinds of groups. (Most facilities I visited for Inside Rehab did not do this, and some providers were not familiar with alternative groups that have been around for decades.)
Wish #6 Truly offer treatment for both substance use and mental health disorders.
According to the most current National Survey of Substance Abuse Treatment Services (N-SSATS, 2014), in just 33 percent of facilities (out of 14,152) the primary focus of treatment was “a mix” of mental health and substance use disorder treatment services. Yet that same year, the National Survey on Drug Use and Health (NSDUH) showed that among the 20.2 million adults in the general population 18 or older with a past year substance use disorder (SUD), nearly 40 percent had a mental illness. It should be noted that, however, when compared to those in the general population, individuals in addiction treatment programs are more likely to have mental health problems – often more than one.
As mentioned in a previous article, many treatment facilities say they treat such co-occurring disorders (or are dual diagnosis-focused), even though what they offer for mental health is minimal. A client at the outpatient program where I work talked about her recent stay at a world-renowned residential rehab that touts itself as providing “integrated” care, addressing both addiction and mental health problems at the same time. During the third week of her 4-week stay, she wondered when the mental health care was going to begin. Before going there, she’d been assured that she would receive treatment for her PTSD. She received only one session for that by the time she left. A therapist at that facility wound up referring her to ours, where we specialize in helping individuals with such problems.
According to Dartmouth Medical School’s Mark McGovern, PhD, a leading expert on how best to treat co-occurring problems, when a facility says it provides such treatment, “This really doesn’t tell people much of anything.” The ideal is to find a facility with truly integrated substance and mental health help treatment – that is, assistance for both conditions in one setting, during the course of the same treatment episode, and by the same team of clinicians (with at least master’s degrees and credentialing in mental health professions) – or to at least have a team of clinicians who can set such a scenario up for clients.
Wish #7 Offer evidence-based help to loved ones of people with SUDs.
As described in one of my early articles for Pro Talk, SUD treatment programs typically offer “family weeks” or “family nights” that teach participants using “psycho educational” lectures and group discussions about the “disease” of addiction, the 12 steps, and Al-Anon support groups. I can find no support for their efficacy aside from some research suggesting that family members involved in Al-Anon reduce their distress and improve their coping skills.
The approach with the most research support for aiding loved ones in getting someone into treatment while at the same time helping family members cope better is Community Reinforcement and Family Training or CRAFT. (We use CRAFT approaches in our family and friends group and find it to also be helpful for loved ones of people currently in treatment.) Developed by Robert Meyers, Ph.D., Research Associate Professor Emeritus at the University of New Mexico’s Center on Alcoholism, Substance Abuse and Addiction, CRAFT has consistently been shown in research studies to be far more effective at getting resistant people into treatment than strategies like those made famous on the TV show, Intervention, whereby family members confront the addicted person about his or her behavior in the presence of an “interventionist” and then try to get the person to enter treatment. Furthermore, family members have reported a marked reduction in their own adverse physical symptoms, depression, anger, and anxiety after participating in CRAFT training. Unfortunately, facilities that offer CRAFT are few and far between.
A listing of certified CRAFT therapists is available at Dr. Meyers’s website, and his book, Get Your Loved One Sober, can be helpful for those who don’t have access to a CRAFT therapist or group. CRAFT materials can also be found at the website of the Center for Motivation and Change. Their excellent book is Beyond Addiction: How Science and Kindness Can Help People Change. (See my article on the new CRAFT on-line program for loved ones of adolescents and young adults.)
Wish #8 Provide meaningful continuing care.
When writing Inside Rehab, the renowned William Miller, PhD, Emeritus Distinguished Professor of Psychology and Psychiatry, University of New Mexico, educated me about the importance of not referring to what happens when formal treatment ends as “aftercare” – a widely used term.
His reasoning is that “aftercare” implies something less important than treatment when, in fact, “continuing care” for someone who has to learn to deal with life on new terms is at least as – if not more – important than the formal treatment phase. In a future article, I hope to address current findings on what’s best for individuals when they complete formal treatment, be it residential or outpatient, but I’ll offer a few generalities here. Of course, what’s best is highly individual. However, what happens next, particularly for those with severe SUDs, should be more than referral to recovery groups (such as AA and SMART Recovery); peer “aftercare” meetings at treatment programs, and/or living in unregulated (as is the case in most states), non-professionally supervised sober living facilities that require regular attendance at 12-step meetings and kick inhabitants out if they use.
If addiction is, in fact, a disorder or “a disease” as many professional groups define it, why does treatment end entirely? Why can’t people keep seeing the provider(s) that helped them in the first place on an ongoing basis? And if there’s a major recurrence, why must they start a program all over again? (Treatment should be modified such that it’s not the same treatment over and over again.) Certainly, a continuum of care with long-term professional support – in the location where the client lives – should be in place before leaving a facility. When it comes to support (outside of recovery groups) that extends beyond treatment, for quite some time, William L. White and the advocacy group Faces and Voices of Recovery have been champions of providing a continuum of peer recovery support services in “recovery community organizations” or RCOs in recovery community centers and other diverse settings on a local and statewide scale. According to White, “[RCOs] organize recovery-focused policy advocacy activities, carry out recovery-focused community education and outreach programs, and/or provide peer-based recovery support services.” To learn more about the Association of RCOs and find where they are located in different areas of the country, visit their website.
Since writing Sober for Good, published in 2001, some positive changes in the field have slowly come about. But we still have a long way to go.
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