Bergmark (2010) proposes that three concepts of treatment

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1 Robin Room Commentary Alcohol and drug treatment systems: What is meant, and what determines their development Bergmark (2010) proposes that three concepts of treatment system are in common use. One is a loose categorical descriptive term, referring to an ad-hoc collection of treatment services sharing some characteristics, often including geography and mode of financing. Terms such as alcohol and drug treatment system or substance use service system are indeed commonly used with such a descriptive meaning, with the phrase including also that the services are in some way intended to ameliorate or prevent alcohol- or drug-related problems for those served. This usage drains most of the meaning out of the term system ; as Bergmark notes, the usage does not necessarily claim that the services are components of a discrete entity composed of interrelated parts. Two other usages delineated by Bergmark are programmatic: the system is defined in terms of preferences or a program for changing it. One of these meanings is in terms of what Bergmark describes as an extensive system approach. The emphasis is on the need to link up treatment services specifically oriented to alcohol and drug problems to a wider range of mental and physical health, welfare and correctional services, whether by combining services, referral, cross-training, or other means. Glaser s core-shell model was a version of this extensive system approach, in that the shell was to include a wide repertory of services looking to needs beyond the usual scope of an alcohol or drug treatment service. Included in the ideal of joined-up services is a critique which contrasts the relative specificity of the services provided by treatment agencies with the multiple life and health prob- NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

2 lems of many in the clientele. However, promotion of the ideal often seems to be driven by professional turf claims rather than by evidence of better outcomes; the evidence base that joined-up services necessarily result in improved outcomes is quite thin (e.g., Krahn et al. 2006; Butler et al. 2008). Also, putting alcohol and drug services into a common system with a particular set of other services for instance mental health services may tend to institutionalize neglect of the other dimensions of health and social problems often afflicting the clientele of alcohol and drug services. The third usage, listed first in Bergmark s abstract, is in line (as he notes) with general systems theory in focusing on the interrelations between the units or elements which compose the system. Holder s (2010) paper is an extended essay in this tradition of the meaning of treatment systems. Holder s essay exemplifies characteristics of this tradition described by Bergmark: a strong orientation to rationality and evidence as the basis for redesigning the system s units and relationships. Holder lays out a series of steps to be undertaken to reform any existing collection of alcohol and drug treatment services, with an emphasis on outcomes, intervening variables, and a logic model for system design. While firmly located in Bergmark s third tradition of meaning, Holder s vision includes an element of the second tradition, in that he subsumes treatment services into a wider frame of a total system of community response. For Holder, the evidence base to be considered is what happens to rates of alcohol and drug problems at the population level, not just in terms of improved treatment outcomes among those who come to treatment. Bergmark quotes from work in this tradition a long list of desiderata for a treatment system, beginning with rationality, and notes that it is more a wish list than a practical program. In his conclusion, Holder comes close to agreeing with this in addressing the question of why existing organizations or agencies do not follow his prescription. Governments do not require accountability of treatment results, and resources are limited, he says; As a result, without both accountability and support of routine evaluation, the viability of the proposed systems approach is limited. Thus there seems to be some justification for Bergmark s characterization of the tradition of thinking and usage as a dream of rationality. Bergmark goes on to propose a fourth perspective, switching from thinking in terms of a treatment system to a treatment market. He notes that the advent of government contracting-out of services (as part of what is termed in Europe New Public Management, NPM) has brought a new element of competition into alcohol and drug treatment services. Control is also mentioned as an element in NPM but it seems to me there was also control (often more directly exercised) in the older arrangement of hierarchies of civil-servant treatment personnel. In the U.S., the shift to government contracting-out of alcohol and drug treatment services, either through a master contract or on a case by case fee-for-service basis, occurred already by the early 1980s (Weisner & Room 1984). In the U.S., the motivations for the shift seem to have been more diverse than in the European NPM ideology, arising in part from 1970s idealism about putting governments in partnership with 576 NORDIC STUDIES ON ALCOHOL AND DRUGS VOL

3 non-profit grassroots agencies. However it arises, there is no question that a contracting system brings competition into the service system, which pulls against efforts to join up and increase linkages between agencies. But the extent and effect of competition should not be overemphasized: the agencies under contract understandably put considerable energy into efforts to control their funding environment, and in the small worlds of local service-system politics the result is often considerable stability in the list of contract agencies, even if their tasks may mutate over time. I agree with Bergmark s impulse to develop a more adequate descriptive (rather than prescriptive) analysis of alcohol and drug treatment systems, and I also agree that the market aspect of the system is an important attribute of many systems today an aspect which has substantial influence on how treatment services individually and collectively function and develop. But NPM contracting still does not guide the operation of every piece of the system everywhere. Alcohol and drug treatment does not operate only by competitive contracting out to nongovernmental agencies among numerous counterexamples are US Veterans Administration alcohol and drug treatment, treatment in most prison services, and Medicare reimbursement to Australian primary care doctors for methadone maintenance. A more general conceptualization of this dimension of determinants of the treatment system is in terms of financing, whether directly from a government through competitive contracting, employment or reimbursement of professionals, or voucher systems earmarking resources for specific clients, whether it be indirectly through mandated health or welfare insurance, or whether it be paid from private family or employer resources. While financing is a crucial determinant of any treatment system, it is not the sole determinant. Ideology also plays an important role how alcohol and drug problems are conceptualised, and what are seen as appropriate responses to alcohol and drug use and problems. A recurrent distinction here is whether it is the drug or alcohol use itself which is seen as the object of treatment, or whether it is rather the preventing or mitigating of problems from use. With respect to illicit drugs, there has thus been an ideological divide between harm reduction approaches and treatments focusing on eliminating drug use; for alcohol, there has been an analogous divide between controlled drinking approaches and Twelve-Step approaches focused on abstinence. A partly-related ideological divide has arisen from the strong roles of Alcoholics Anonymous and other mutual-help movements in social responses to alcohol and drug problems in the last 70 years, which have meant that experience-based approaches to treatment have been in ideological and often practical competition with professionalized approaches to treatment (e.g., Stenius 1991). Cross-cultural comparisons of alcohol and drug treatment systems underline that ideological differences also extend in a number of other directions, most notably in the variation in governing images of alcohol and drug problems between societies and across time (Room 2001). A related but distinct set of determinants is the professions and institutions with custody of alcohol and drug problems. Whether the governing image of the problems is in terms of mental disorder, NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

4 physical disease, a workforce, housing or family problem, or a crime tends to have strong influence on which professionals and social institutions will be given prime responsibility. But older governing images typically do not disappear, and institutional and jurisdictional changes may lag well behind ideological changes. Lastly, an important set of determinants of alcohol and drug treatment systems is the social standing and power position of the clients. Bergmark discusses the divergence from the classic concept of the market involved in the fact that the purchaser of the treatment services is usually not the client, so that the needs of the client are often defined by someone else rather than by client preference. But the split between purchaser and client exists also for any publicly-funded health service, and while the client typically has considerable say concerning his/her needs in such a system, the purchaser there also has a say. What is different about alcohol and drug treatment services is that the clients are very often marginalized and stigmatised; indeed, there is usually a stigma around the very fact of coming to alcohol or drug treatment (Room 2005). Often those coming in the service door are under considerable coercion, whether from courts or welfare workers or informally from family and friends (Storbjörk & Room 2008). In these circumstances, the clients are not in a good bargaining position concerning what services are offered to or pressed on them. The greater the degree of coercion in the system, the more it can be organized so the benefit to the clients is secondary to the convenience of those staffing the system. That the clients preferences may have little influence on what services a particular agency offers them means that, from the point of view of the clients own preferences, they benefit from a greater variety of choices between agencies, and may lose options if the agencies become more joined up and rationalized into a system sharing client information between agencies. The clients of services on Skid Row in San Francisco (Wiseman 1970), for instance, had more choices with a system that was fragmented than they would have had with an integrated system. The social position of the clients thus affects not only the provision and funding of services but also the extent to which the integration of services would be viewed by the clients positively or negatively. In my view, financing modes and practices, ideological frames, patterns of professional and institutional jurisdiction, and the clients social power situation all play important roles in the construction, development and functioning of alcohol and drug treatment systems. Each of these aspects is interconnected; financing, for instance, influences ideology, and vice-versa (Weisner & Room 1984). Yet variables in each domain also play an independent role in how systems are defined and change. Attention to each domain is thus needed in descriptive and comparative analyses of alcohol and drug treatment systems as they actually exist and develop. Robin Room, professor Centre for Social Research on Alcohol & Drugs Stockholm University, Sweden; School of Population Health University of Melbourne; AER Centre for Alcohol Policy Research Turning Point Alcohol & Drug Centre Fitzroy, Vic. Australia NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

5 REFERENCES Bergmark, A. (2010): On the idea of treatment systems. Nordic Studies on Alcohol and Drugs 27 (6): Butler, M. & Kane, R.L. & McAlpin, D. & Kathol, R.G. & Hagedorn, H. & Wilt, T.J. (2008): Integration of Mental Health/Substance Use and Primary Care, Evidence Report/Technology Assessment No AHRQ Publication No. 09-E003. Rockville, MD: Agency for Healthcare Research & Quality, U.S. Department of Health & Human Services. pdf (accessed 19 Dec., 2010) Holder, H.D. (2010): Substance abuse treatment as part of a total system of community response. Nordic Studies on Alcohol and Drugs 27 (6): Krahn, D. & Bartels, S.J. & Coakley, E. & Oslin, D.W. & Chung, H. & McIntyre, J. & Chung, H. & Maxwell, J. & Ware, J. & Levkoff, S.E. (2006): PRISM-E: Comparison of integrated care and enhanced specialty referral models in depression outcomes. Psychiatric Services 57, full/57/7/946 (accessed 19 Dec., 2010) Room, R. (2001): Governing images in public discourse about problematic drinking. In: Heather, N. & Peters, T.J. & Stockwell, T. (eds.): Handbook of Alcohol Dependence and Alcohol-Related Problems. Chichester, UK, etc.: John Wiley & Sons Room, R. (2005): Stigma, social inequality and alcohol and drug use. Drug and Alcohol Review 24: Stenius, K. (1991): The most successful treatment model in the world : introduction of the Minnesota Model in the Nordic countries. Contemporary Drug Problems 18: Storbjörk, J. & Room, R. (2008): The two worlds of alcohol problems: Who is in treatment and who is not? Addiction Research and Theory 16 (1): Weisner, C. & Room, R. (1984): Financing and ideology in alcohol treatment. Social Problems 32 (2): Wiseman, J.P. (1970): Stations of the Lost: The Treatment of Skid Row Alcoholics. Englewood Cliffs, NJ: Prentice-Hall. NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

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