Program Thinking: The Bane of Addiction Treatment

I appreciate the two comments on my last blog, and they prompt a couple of responses from me. (If you didn't read them, click on the "Comments" link at the bottom of the blog.)

First, I'd like to clarify something in response to Dr. Dawson's comments. I was not arguing that people who are living in a sober structured environment do not need programming, or do not benefit from it. What I am saying is that there is no such thing as "residential or inpatient treatment." That is, studies have shown that staying overnight in the same place while receiving treatment has no outcome advantages over going home or to some other place, like a sober residence. So, there is treatment, and there is housing structure. Just like addiction psychotherapy, addiction pharmacotherapy, vocational counseling, psychiatric treatment, treatment for conditions below the neck (CBTN) (often but erroneously called "physical or medical" as opposed to "psychiatric," as if psychiatric conditions were somehow not organ-based or medical), transportation, family or marital therapy, and so on, addiction psychotherapy and housing structure are two very important, but essentially independent components of an interdisciplinary approach to comprehensive modern addiction treatment.

Marrying addiction psychotherapy to a residential treatment bed leads to "program thinking." Program thinking promotes a number of undesirable behaviors or characteristics. First, there is constant pressure to "keep the beds full." Thus, inclusion/exclusion criteria become flexible depending on bed occupancy, and people who could be treated quite well as outpatients are instead admitted to a residential program. This constant push leads to excessive costs without adding to outcome. Second, program thinking leads to cookie-cutter programming, because it's like running a factory, churning out patients and it is too difficult to have completely individualized lengths of stay or treatment plans. For example, the old joke in rehab is that we conduct a comprehensive individualized assessment and then send the client to group. It works much better to have the same groups for everyone, the same treatment for everyone, every time. Third, it leads to inappropriate levels of housing and of treatment services. Some people who need longer-term housing are pushed out at the end of the "program," while others who don't need sober housing are forced into it (and to pay for it.) Some patients need more intensive and comprehensive treatment services for a long time, but their treatment is interrupted arbitrarily, often with devastating consequences such as recurrent addiction along the way to connecting with some (different) outpatient follow up (inappropriately called "aftercare" rather than "care"). When treatment services are provided independently, then there is no disruption of services when a patient moves from one level of housing structure to another. Lack of continuity is compounded when the residential facility is geographically distant from the patient's home, which is often the case. It is always tempting to "send the patient away" to a distant facility so we don't have to worry about whether they are safe, but if we did that with every condition, we'd be sending out of control diabetics, not to mention almost all adolescents, to residential treatment too. We used to hospital people for long periods for psychiatric disorders such as depression and anxiety too, but when it became clear that that was actually harmful and expensive, it was stopped. It is long past time to stop it for addiction treatment too.

I'll respond to the other comment later.

Keep the comments and dialogue coming!

MW