The American treatment systems

I stumbled upon this article today on what The Meadows treatment program can teach the U.K. treatment system.

I assume that The Meadows is a fine treatment program, but its framing as representative of the American treatment system is curious. It’s certainly representative of one American treatment system—the one available to very rich people.

The truth is that residential treatment of any kind is out of the reach of most Americans today. Trade publications refer to “affordable” treatment as any program that costs less than $20,000 a month. (Dawn Farm is about $2700 a month. We have a donation funded wait-list for those that can’t afford our fees.) Most Americans will find relatively easy access to outpatient treatment for a period of 8 to 20 weeks, but little more.

Also, to a significant extent, specialty addiction treatment programs have become a thing of the past in America. Most treatment services are delivered in multiservice or mental health settings.

Worse yet, I fear that health care reform and integration into the medical system will result in a system that places primary care physicians on the front line to prescribe medications to treat addiction without a lot of support behind them.

This is not new. Bill White has written extensively about it in Slaying the Dragon:

Diffusion and Diversion

Diffusion and diversion constitute two of the most pervasive threats in the history of addiction treatment institutions and mutual-aid societies. Diffusion is the dissipation of an organization’s core values and identity, most often as a result of rapid expansion and diversification. Diffusion creates a porous organization (or field) that is vulnerable to corruption and consumption by people and institutions in its operating environment. Diversion occurs when an organization follows what appears to be an opportunity, only to discover in retrospect that this venture propelled the organization away from its primary mission.

The current absorption of addiction treatment into the broader identity of behavioral health is an example of a diffusion process that might replicate two earlier periods – the absorption of inebriate asylums into insane asylums and the integration of alcoholism and drug-abuse counseling into community mental health centers in the 1960s. This diffusion-by-integration has generally led to two undesirable consequences: 1) the erosion of core addiction treatment technologies; and 2) the diversion of financial and human resources earmarked to support addiction treatment into other problem arenas.


A Panicked Field In Search of Its Soul and Its Future

In the face of such threats (managed care, facility closures, merger mania & integration into behavioral health systems), the field is experiencing a strange phenomenon. As the core of the addiction treatment field shrinks, the field is growing at the periphery. Where the total amount allocated to residential and inpatient treatment services is shrinking, the numbers of outpatient services is actually increasing, as is a growing number of new specialty programs that extend addiction treatment services into allied fields. The growth zone of the addiction treatment industry is not at the traditional core but in the delivery of addiction treatment services into the criminal justice system, the public health system (particularly AIDS related projects), the child welfare system, the mental health system, and the public-welfare system. If one looks at these trends as a whole, what is emerging in the 1990s is a treatment system less focused on the goal of long-term personal recovery than on social control of the addict. The goal of this evolving system is moving from a focus on the personal outcome of treatment to an assurance that the alcoholic and addict will not bother us and will cost us as little as possible.

The fate of the field will be determined by its ability to redefine its niche in an increasingly turbulent health-care and social-service ecosystem. That fate will also be dictated by more fundamental issues – the ability of the field to: 1) reconnect with the passion for service out of which it was born; 2) re-center itself clinically and ethically; 3) forge new service technologies in response to new knowledge and the changing characteristics of clients, families, and communities; and 4) the ability of the field to address the problem of leadership development and succession.

Two more thoughts: First, we are in the early stages of a rebirth of the treatment system. Bill White’s models of Recovery Management and Recovery-Oriented Systems of Care are responsible for this rebirth. Second, it’s a strange phenomena that some of these exorbitantly priced programs offer the closest thing to grass roots treatment that emerged from the failure of these other systems.

I’m grateful to work in one of the few specialty addiction settings that has stayed connected to the recovering community, continued to focus on long-term treatment and recovery support, and kept services within reach of regular people.



One thought on “The American treatment systems

  1. I saw this article too and wondered. My conclusion was that you couldn’t tell anything about the differences in treatment approaches from the examples they chose.

    I think the warnings on diffusion and diversion are well made. Like you, I’m fortunate to work in a setting with good access pathways into treatment with strong connections to local recovery communities.

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