This post was written with Alan Cudmore
Elizabeth Bradley and Lauren Taylor have written a brilliant analysis of the American health care system. They point out that, examining direct health care costs, America spends far more per capita than any other nation. But if you expand that net "to include spending on social services, like rent subsidies, employment-training programs, unemployment benefits, old-age pensions, family support and other services that can extend and improve life," America drops far lower in the rankings.
Their argument is, of course, that these social services are the fabric of health -- that people are not going to be healthy if they haven't got secure places to live, support for their lives, and nurturing social networks. The same goes exactly -- more so -- for addiction treatment. Some years ago, in American Psychologist, Keith Humphreys developed a very similar analysis of American substance abuse treatment. That is, Humphreys showed, money had been drained from social support services to provide addiction rehab.
Of course, this follows on the idea of addiction as a disease. If it is a straightforward result of brain chemistry or some other biological process, then how better to deal with it than through medicine? But the idea that addiction stems from a failure to make needed connections -- of purpose, intimacy, community, family, health, career, and education -- in life recasts the entire idea of treatment. In this regard, the same differences that Bradley and Taylor note in American health care apply to international differences in addiction treatment.
Other countries (e.g., Canada and the UK) build their substance treatment around community-based addiction services. That is, there may be drop-in centers, or community outreach visits, or visits to schools. And the information that is conveyed -- and the services that people can access -- aren't primarily treatment ones. They are services that offer connections to life -- job training, education, health care, social support services. It is remarkable -- but obvious -- how many more people can be reached at much lower costs in this fashion. Equally important, these connections can be more readily maintained over time when the community worker is available where the person lives.
It is instructive to consider how we have restructured mental health services in almost the opposite way than addiction-specific services have been developed, even though addictions and mental disorders share many of the same risk and protective factors. Let's take schizophrenia as an example. At one point in history, the ‘best' approach was understood to be to lock people with schizophrenia in hospital wards where they would remain for long stretches of time, often their entire lives. Research, however, made clear that being shunted off for months and years in a hospital actually makes people with schizophrenia worse. The result has been the deinstitutionalization of the mental health care system in favor of community-based mental health services (such as Assertive Community Treatment Teams and Intensive Case Management) that allow people with serious mental illness to receive treatment along with different types of support (housing, vocational, recreational, social). The outcomes of this approach are better than the institutional model, as well as being far less expensive.
The evolution of care in the case of mental illness is especially noteworthy since there is more evidence of genetic or disease factors that play a role in the development of schizophrenia than in addiction; yet that field has moved more quickly and firmly towards integrating the individual's support needs in the recovery process than the addiction field has.
We in the U.S. think of addiction treatment as being embodied by the Betty Ford Center, or Hazelden - 30-90 days of intensive, extremely expensive counseling, groups, and diet-exercise-vitamin programs. If people can afford such care -- or their insurance covers it -- they demand such a cocoon-like environment and health-spa-like setting. But this kind of coverage can reach only a miniscule part of the population -- and that part for only a brief time. It is altogether too expensive to comprise a general basis for addiction services.
In the province of Ontario, in Canada, on the other hand, individuals accessing publicly-funded addiction services are assessed with standardized tools and criteria, and an individualized treatment plan based on motivation, severity, and need is recommended. Once assessed, the client is referred to a range of services, from brief community-based counseling all the way to long-term residential treatment. Within this system, the more intensive and expensive long-term residential programs are reserved for those with the most severe addictions and who are also motivated to participate in this type of treatment.
In the U.S., the alternative to the intensity of residential rehab is AA and similar informal support services provided by members themselves in a non-professional way. These is nothing wrong with having such services available, but they too will only reach a small percentage of people. That is, AA often fails to draw in and maintain those who need the service most -- the seriously alcohol dependent or, at the opposite extreme, younger and less long-term substance abusers who are unlikely to utilize a service marked for people with chronic substance problems and dependencies.
That American health care services of all types tend to take the form of such intensive, high-cost, short-duration service provision is due to an outlook that we tend to have here that we can purchase our health and our sobriety or otherwise get it in a short consumer or inspirational burst. But health and sobriety are about long-term relationships we have to life, the world, our communities and ourselves. And these take considerably more comprehensive interventions than those available in rehab residences and church basements, the main places treatment is currently available in the United States.
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