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Putting the Patient Back into Treatment: Collaborative Determination of Treatment Goals

Fred Rotgers, Psy.D., circa 2000

For years addictions treatment programs have operated on the assumption that patients with addictions are,  
1) in denial about the need to change their substance use, and,
2) incapable of understanding the need to become abstinent. 

As a result of this philosophy, many programs have insisted that patients choose the goal of abstinence from all substances as a pre-requisite for admission to treatment.

We 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.

Many 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.

We 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

Another 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.

For 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 medical practice

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Booth, P.G., Dale, B. & Ansari, J. (1984). Problem drinkers’ goal choice and treatment outcome: A preliminary study. Addictive Behaviors, 9, 357-364.

Cannon, 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.

Morgenstern, 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, 53-64.

Ojehagen, A. & Berglund, M. (1989). Changes of drinking goals in a two-year outpatient alcoholic treatment program. Addictive Behaviors, 14, 1-9.

Pachman, 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.

Parker, 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.

Perkins, 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.

Sanchez-Craig, M. & Lei, H. (1986). Disadvantages of imposing the goal of abstinence on problem drinkers: An empirical study. British Journal of Addiction, 81, 505-512.

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Dr. DeLuca's Addiction, Pain, and Public Health Website

Alexander DeLuca, M.D.

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Originally posted:  Circa 2000

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