Alexander DeLuca, M.D.
Putting the Patient Back into Treatment: Collaborative Determination of Treatment Goals
Fred Rotgers, Psy.D., circa 2000
years addictions treatment programs have operated on the
assumption that patients with addictions are,
take a different approach, based on research and sound medical
practice. We trust our patients to be experts in their own
concerns, just as they trust us to have effective treatments
available to help them sort out the turmoil they are
experiencing, and begin to lead healthier lives. For this
reason, treatment goal selection (abstinence or reduced use) is
a collaborative process here.
practitioners trained in the “old school” recovery model
methods may say to patients that this is not a viable approach.
There is an old myth among treatment providers that if one “allows”
an addicted patient to choose his/her own goals, then almost
invariably the patient will choose to continue using at a
reduced level, rather than choosing abstinence. These
practitioners feel, as a result, that abstinence must be imposed
as a goal, and treatment be made contingent upon the patient
accepting that goal right from the start. However, research has
clearly shown that this practice can result in poorer
outcomes, regardless of the goal imposed.
prefer to base our practice on research rather than clinical
lore and myth. What does research tell us about what patients
want and do in selecting treatment goals? In fact, the research
(see Bibliography for these references) clearly debunks the myth
that patients, offered the option, will almost always choose
continued use. There have been numerous studies in which
patients have been offered this choice (between abstinence and
reduced use goals), and the results are striking. On average,
more than 75% of patients offered this choice when they enter
treatment choose abstinence! Over the course of treatment, about
half of the remaining 25% shift their goal from reduced use to
abstinence! Thus, the research clearly shows that, when offered
a choice, patients often make the healthiest ones. This is
consistent with our experience here at Smithers
factor that research has found to be clearly important to
successful achievement of one’s treatment goals is commitment.
Studies have shown that the single best predictor of goal
achievement is the degree of commitment the patient has to that
goal at the start of treatment. If the patient is committed to
abstinence, he/she is more likely to achieve that goal, than if
commitment to abstinence is low. If the patient is committed to
a reduced use goal, he/she is more likely to achieve that goal
than if he/she is not committed to it.
these reasons, we have re-designed the Smithers evaluation and
treatment programs to be collaborative with patients in
selection of treatment goals. While we make recommendations to
our patients as to what we think (again based on our clinical
and research knowledge) would be most helpful, the decision of
which course to pursue always rests ultimately with the patient.
And if the patient chooses to not to take our suggestions, we
choose to continue working with them to mitigate harm and to be
there if they stumble. This is what we mean by fostering a
collaborative relationship with the patient. We believe that
this approach represents the state of the art in addictions
treatment, and is fully consistent with principles of excellent
P.G., Dale, B. & Ansari, J. (1984). Problem drinkers’ goal
choice and treatment outcome: A preliminary study. Addictive
Behaviors, 9, 357-364.
D.S., Baker, T.B. & Ward, N.O. (1977). Characteristics of
volunteers for a controlled drinking training program. Journal
of Studies on Alcohol, 38, 1799-1803.
J., Frey, R., McCrady, B., Labouvie, E. & Neighbors, C.J.
(1996).Examining mediators of change in traditional chemical
dependency treatment. Journal of Studies on Alcohol, 57,
A. & Berglund, M. (1989). Changes of drinking goals in a
two-year outpatient alcoholic treatment program. Addictive
Behaviors, 14, 1-9.
J.S., Foy, D.W. & Van Erd, M. (1978). Goal choice of
alcoholics: A comparison of those who choose total abstinence
vs. those who choose responsible controlled-drinking. Journal
of Clinical Psychology, 34, 781-783.
M.W., Winstead, D.K. & Willi, F.J.P. (1979). Patient
autonomy in alcohol rehabilitation: A literature review. International
Journal of the Addictions, 14, 1015-1022.
D.V., Cox, M.W., & Levy, L.H. (1981). Therapists’
recommendations of abstinence or controlled drinking as
treatment goals. Journal of Studies on Alcohol, 42, 304-311.
M. & Lei, H. (1986). Disadvantages of imposing the goal of
abstinence on problem drinkers: An empirical study. British
Journal of Addiction, 81, 505-512.
|Alexander DeLuca, M.D.||
Originally posted: Circa 2000
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Most recently revised: 4/30/2004