Treating addiction in an open, psychodynamically oriented hospital setting provides challenges that may suggest the need for a paradigm shift in how professionals treat addiction in other settings, as well. The challenge of integrating psychiatric and addiction treatment exists in many settings, as the health field strives toward establishing wraparound, interdisciplinary, and seamless systems of care. Several areas of conflict in this move toward integration offer a conceptual framework suggesting a more modern approach to treating comorbid disorders, which was arrived at through this writer's efforts to establish a substance abuse service in a psychoanalytically oriented hospital treatment center. These areas include exploring similarities and differences between mental health and addiction treatment and developing a clear understanding of role-specific authority in implementing an interdisciplinary treatment model.
An “open setting,” as defined by this hospital's mission statement, is on the one hand characterized by the absence of seclusion rooms, restraints, and locked doors, and on the other by the assumption that life and its interactions are worth ongoing examination.
The Austen Riggs Center, located in the picturesque Berkshire Mountains of western Massachusetts, has been traditionally known as a long-term treatment facility with roots dating to the days of rest homes, socialized therapeutic work programs, and sanitariums of the early 20th century. The center blends in with the local architecture of “cottages” and centuries-old colonial homes lining the town's main street. Patients participate in various levels of care in which they hold ultimate responsibility for their own safety under the scrutiny inherent in active therapeutic community group life. Many patients have cars and jobs and attend school.
The most prominent aspect of treatment is psychoanalytic therapy offered four times per week; all patients attend regardless of level of care. Other services are provided by social workers, medical staff, psychiatric nurses, psychopharmacologists, substance abuse professionals, and an activities staff that offers a clinical-free zone where patients can become students of woodworking, weaving, pottery, theater, photography, and horticulture. The center operates a Montessori school in which patients are able to take part through volunteering or paid internships and an active work program.
Within a short walk of the center, the village offers various shops and restaurants, with many cultural events nearby. This environment includes bars and a modest offering of nightlife catering to the local population and an influx of summer tourists. While the setting's openness might at first seem to be a drunkard's dream, its challenges are an integral part of treatment—there is little effort to shelter patients from the “people, places, and things” with which they ultimately will have to deal. One can literally walk the same distance to a nightclub or to an AA meeting. All patient experiences are grist for the mill of ongoing examined living. This arrangement is not for everyone, and in fact many prospective clients with an active substance abuse problem are referred to addiction-specific treatment facilities in order to establish a viable period of sobriety before admission is considered.
Shedding old stereotypes
As an institution with traditions incorporating many of the tenets of psychodynamic treatment, the center has had its share of conflict in developing a substance abuse service element. The center has been in operation for more than 75 years but has had specialized substance abuse counselors for only the past 10 years. The traditional psychoanalytic tendency was to view addictions as highly defended symptoms meant to obtain pleasure or relieve tension from pathology of underlying origin. The thought was that once the conflict was uncovered and solved through the analytic process, the substance abuse then would resolve as a symptom no longer needed, allowing the real work to begin.
But the changing demographics of the population seeking treatment at the center (or anywhere else for that matter) strongly suggest that dual diagnosis is the norm rather than the exception, and that development of an addictive disorder can occur in varied forms, most often within the context of other Axis I and II diagnoses. Truly, the dually diagnosed no longer are seen as a “special population.”The growing concern for containing healthcare costs and the resulting competition for limited resources have erected obstacles to a truly integrated model of treatment under an interdisciplinary staff. The impact of the 12-Step fellowship has challenged the psychoanalytic tradition's view by suggesting that recovery occurs best through one recovering person helping another (rather than solely through developing a transference/countertransference relationship between patient and therapist).
These traditions of self-help also provided the groundwork for a growing field of substance abuse treatment as the disease model began to take hold through the advocacy of the medical community. As a wide range of services proliferated, the self-help community was tapped for its most vital resource: people who had gained experience working with others with substance abuse problems.