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Were the old times better?

May 6, 2009
by Tom Moore
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Pining for a 'golden age' of treatment ignores recent progress in care quality

The short-lived television series “Life on Mars,” in which a police officer is transported back more than 30 years to 1973, did an extremely credible job of comparing the present to a time when there was no talk of DNA testing, compassion fatigue among first-line responders, or intervention for on-the-job substance use. When I watched the show it caused me to reflect on my entry into the recovery field 30 years ago. People often talk about that time as the “good ol’ days” of treatment or the “golden age” of recovery. But was it really? What can be agreed upon is that today we have seen managed care’s impact on the field, we see providers barely getting by with frozen funding, and we observe the treatment field becoming tenuously dependent on criminal justice system referrals. Yet at the same time, I would assert that the quality of care has continued to increase.
Ups and downs
The first six months of my career were spent in prevention. After all, I thought I knew something about street drugs and the nomenclature of the day. While in high school, I had attended a convocation in which two graduates of Phoenix House in New York City arrived in miniskirts and talked about their past use and entry into treatment, even using the F-word in front of the principal and teachers. So if I was hip enough and read High Times, what else did I need to know? Within six months of my arrival, our prevention department disbanded (we couldn’t prove what was prevented). I was absorbed into the counseling center. I overheard one support staff member telling another about a colleague who had made the same transition. She stated, “It changes all of them.” It certainly changed me and my worldview. I still wince about my early clinical work with very ill clients, feeling so inadequate that I wanted to hang the Dante quote “Abandon hope all ye who enter here” over my door. Yet I was astute enough to understand that by doing so, there would be no return customers. In my local municipality, a merger occurred several years ago between the substance abuse coordinating agency and the local mental health authority. Many predicted disaster, but what resulted instead was incredible innovation, and no erosion of community-based addiction services. Back in the early 1980s, most treatment had been initiated within hospital-based programs, outpatient care was considered “aftercare,” and programming was rigid and predictable—repeated viewings of lectures and films that patients had memorized. Many old-timers will remember the schism that existed in those days, with counselors who were graduates of therapeutic communities or had other recovery experiences remaining quite suspicious of those with professional training. Many concepts had not yet arrived, including acceptance of different paths to recovery, establishment of smoke-free 12-Step meetings, and programs’ acknowledgement of diversity in the recovery population. Co-occurring disorders, harm reduction and cognitive-behavioral therapy were among the items not yet on the clinical horizon. I remember sitting in group rooms furnished with large pillows and beanbag chairs, encouraging clients to discharge feelings in what I have come to call a “projectile vomiting of emotions.” Other programs held marathon encounter sessions and broke down egos and defenses. I met one client from another facility who had been forced to wear a toilet seat around his neck for a week. We told clients, “If you keep doing what you have always done, you will keep getting what you have always gotten.” Yet as professionals, we repeated strategies and techniques that benefited few, and we labeled those who relapsed as “not ready to change.” Staff in one residential program were fond of saying, “There are 20 potential other admits for this bed, so hit the road and come back when you are ready.” Not exactly what we would consider welcoming or stage-specific interventions today. After establishing an intensive outpatient program in 1985, our agency was accused by other treatment facilities of setting up clients to fail, because the treatment “authorities” stated that effective treatment could only consist of a 28-day inpatient program. We also were rebuffed by insurance companies that could not conceptualize organizing outpatient treatment in such a concentrated way. We experienced some wrong turns, such as termination of unlimited insurance benefits and several local treatment facilities meeting their demise. But there also were gains, including patient placement criteria, Motivational Interviewing, peer support, and trauma-informed services. The demographics of the recovery population changed: less Caucasian, less male, less heterosexual, and more diverse in drug of choice. Personal changes also occurred: crossing the line with my own substance use, the ending of a marriage and estrangement from children, entry into a 12-Step program, increased humility and sensitivity, and, on the best days, serenity. I gained the opportunity to carry the message.
Don’t look back
So would I want to go back to 1979 and relive those years as on “Life on Mars”? About as much as I would like to re-experience disco, the Commodore 64 computer, and reruns of “Three’s Company.” Challenges still exist, of course. There is a need to individualize care further, to integrate technology at the documentation and service delivery level, to recruit younger people as field professionals, to enhance competency in serving clients with complex needs, to gain community acceptance for medication-assisted treatment, and to establish recovery-oriented systems of care. In looking forward to these and other accomplishments, I relish the already attained improvements in care, marvel at the increased community understanding of recovery, hope some of those with whom I crossed paths benefited, and continue to give thanks for another 24 hours in recovery.