What Is “Treatment?”

What is “Treatment?”

5/15/2018

I have a colleague who shared a story of a patient who told him he’d “been in treatment 32 times.” 32 times? How is that possible? How is that patient ever NOT in “treatment?”

It turns out, of course, that the patient was referring to detox events. He’d been briefly hospitalized (or clinically managed) for periods of time after heavy drug/alcohol use, then discharged. Depending on a person’s use history–amounts and frequency–abruptly stopping use can be medically dangerous. In fact, when alcohol is the substance in question, it can be life-threatening.

 

But “detox” is not treatment.

 

I hear many stories about patients who enter clinics or “rehab” centers, and there experience a saturation of 12-step activities and materials, with perhaps some units on biology via the metabolization of drugs and alcohol, and not much else (12-step refers to the program more well known as Alcoholics Anonymous and its offshoot organizations). At these places, there is attendance at 12-step meetings, speakers from 12-step groups, reading of 12-step literature, and the ever-popular creation and sharing of the patient’s “First Step,” which–as the name implies–is an iteration of the first of the twelve steps (it’s a condensed life history with a focus on drugs and alcohol and how the patient became powerless over their use). Patients–and insurance companies–are charged a hefty fee for this service. But attendance at any Alcoholics Anonymous meeting is free. Why pay for treatment, then?

 

Alcoholics Anonymous is not treatment, either.

 

To be clear: The fellowship of 12-step groups like AA, NA, etc. has saved countless lives over the 80-plus years it’s been in existence. This peer support network has provided ongoing help for many, many people and is invaluable for those who find it the right fit, and determining that fit requires a period of attendance at a variety of meetings. But the idea that an organization can and should call 12-step work “treatment” and charge for that service is highly problematic.

Substance Use Disorder (SUD) treatment is a specific process that includes a careful and deliberate diagnostic assessment–aligned with the American Society of Addiction Medicine’s criteria–and a plan of action based on that assessment. Levels of care (inpatient, outpatient, partial-hospitalization, etc.) and treatment programs are determined through this assessment. The patient then undergoes an intake process and receives support and education, in a group environment and/or individual counseling, using a variety of clinical approaches such as Motivational Enhancement, Contingency Management, Cognitive Behavioral Therapy tools, et al. A good clinician evaluates each patient’s strengths, provides information, structure, guidance and support, and incorporates patient goals into an ongoing treatment plan.

Additionally, at a high-quality agency, these are things that happen without blaming patients for their disorder, or even for their ambivalence about making changes. A patient shouldn’t be made to feel judged, ridiculed or shamed –especially after having made the effort to get assistance–even if they struggle to maintain abstinence. Good treatment clinically treats what we know is a chronic disorder.

 

Drug and alcohol use disorders can be addressed in a wide variety of ways. There are people who make all the changes they need to make on their own or by attending 12-step groups (that is, with no treatment at all). There are people who address problematic drug or alcohol use in a therapeutic setting with a licensed psychotherapist or mental health professional, while working on other issues as well. Many people find medication-assisted programs very helpful–optimally in conjunction with treatment or therapeutic support. Some people try several different approaches before they find what works for them; they quit on their own for a while but start drinking or using again, or they go to 12-step groups for a period of time, for example, but feel they need something different. Treatment is one of the options for addressing maladaptive or problematic drug or alcohol use, and good treatment at a high-quality agency is always a choice that will work in your favor.

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