“Low Barrier” Treatment Options
By Tom Horvath, PhD
This month the Substance Abuse and Mental Health Services Administration (SAMHSA) of the federal government released a 15-page document entitled Advisory: Low Barrier Models of Care for Substance Use Disorders. The document summarizes the difficulties associated with reaching and providing care for individuals with substance use disorders. Less than 10% of individuals who might benefit from treatment participate in it. A “low barrier” approach to treatment attempts to reduce the difficulties that might reduce treatment attendance.
Although not primarily intended as a list of the shortcomings of the current US addiction treatment system, the document can be understood that way.
What’s wrong with US addiction treatment?
Too many requirements for entry. The insurance system is not the fault of treatment centers. They have no choice but to live with it. Ideally someone should be able to show up and start getting meaningful help immediately. Unfortunately, getting insurance approval can take hours or days, and is not guaranteed. What treatment centers can control is whether they require multiple screening and evaluation appointments, or have waiting lists, or place other obstacles in the client’s way. These obstacles can stretch over days or longer. With addictive problems motivation to change can fluctuate rapidly. Many clients are given so much time they change their minds. Of course, providers need to do basic screening and assessment before initiating treatment, but when the client is viewed as a partner that process can go quickly.
Too few options about how treatment will unfold. If you don’t like 12-step, disease-oriented care, you may need to look a long time for alternatives. You may also have difficulty finding treatment aligned with your cultural or racial background, with your gender only, or that allows goals other than abstinence. Treatment needs to be personalized to the background, goals, and values of each client. Personalization requires that individual sessions be frequent. Groups can have a very important role in treatment, and can be personalized to a degree, but not to the extent that individual sessions can be.
Stigmatizing, judgmental perspective. The labels “addict” and “alcoholic” are at the beginning of some treatment centers work with someone. You need to accept these labels (and the existence of an underlying disease) before much else happens. This approach works well for some, but others can be left uncared for. Furthermore, the concept of “powerless over my substance” can easily (but inaccurately) be expanded into “powerless over everything.” If you are powerless over everything, then your judgment and desires are not worth considering. The providers can treat you as a not fully competent person who deserves to be ordered around. Consequently, your background, goals, and values may not be given adequate consideration.
Limited focus. Good addiction treatment addresses the whole person, not just the addictive problems. Individuals with addictive problems also have other problems, which do not automatically disappear when the addictive problem gets resolved. The related problems may be contributing to the addictive problem. Resolving related problems may be necessary for a long-term resolution of the addictive problem. If I’m depressed and use alcohol to cope with depression, maybe the depression will resolve with abstinence. However, an additional focus on treating depression may be necessary. If trauma is part of one’s experience (and it often is with addiction), including that focus in treatment can be essential.
Low level staff. To provide quality addiction treatment requires quality staff. Should not a potentially life-threatening disorder be worthy of master and doctoral level providers, who have training that goes beyond their own life experience of addressing their own problems? Any treatment facility needs a range of staff, just as a hospital has doctors, nurses, vocational nurses, orderlies, and a wide range of specialized staff. You would be very concerned about a hospital that had vocational nurses as the primary staff.
How could we move forward?
Any treatment that does not have the above problems would be a major advance over most US treatment. Such facilities exist, but it can take major effort to find them.
Alternatively, SMART Recovery and other self-empowering mutual help groups have complete and immediate accessibility (online), at no cost, and do not exhibit the above problems. To focus on SMART specifically (which is the largest of the self-empowering mutual help groups), we find many aspects of low barrier care. SMART offers:
Person-centered care. SMART encourages participants to empower themselves to take responsibility for their own process of change, while providing them with a supportive environment in which various approaches for making change are discussed.
Progress-oriented approach. This orientation is also referred to as harm reduction. In SMART each participant establishes their own goals. Although abstinence is a fully acceptable goal, it is not required. Many participants choose to abstain from some substances, but not others. Many are still in the exploratory phase, and do not even know what their goals are. All are welcome. Participants respect the necessity that for goals to be meaningful they must be freely chosen.
Flexibility. Participants can attend as often or as little as they like. They are free to talk about any relevant subjects, or not speak in a meeting at all.
Whole person approach. Although there are limits on what can be done in a mutual help group, SMART supports individuals seeking out other important services, and is supportive of hearing in a meeting about those services and their helpfulness.
Responsive and inclusive care. Because SMART does not have a specific program of care, individuals from diverse backgrounds are free to share what has influenced them positively and negatively, and what they are seeking. Groups simultaneously work to understand how each person is unique, and how the participants are all human beings. Participant goals will be similar to the extent we are human, and unique to the extent we are unique humans. Helping each other identify both types of goals (common and unique) is beneficial to all participants.
How could SMART become more available?
SMART (founded 1994) will continue to grow as individuals who discover it become champions for advancing it. SMART needs individuals to volunteer to facilitate meetings (using a variety of formats, some of which are easy to learn). SMART does not require facilitators to have a personal background with addictive problems. Anyone interested in promoting the health and well-being of their community is welcome. Often family members of individuals with addictive problems find facilitating to be a meaningful way to invest their energy.
SMART, like any non-profit, needs funding. SMART could increase the number of its meetings more rapidly if it were funded to hire individuals to facilitate meetings (and not just rely on volunteers), and pay rent to secure desirable meeting locations for face-to-face meetings.
SMART is already funded by donations from meeting participants, and the generosity of large donors. Government funding would allow SMART to make major changes in the addiction treatment landscape, and for a modest cost (given what the government already spends on addiction treatment). Once SMART became fully available, the addiction treatment system would almost necessarily change. Treatment clients, having experienced SMART, would no longer tolerate the problems described above.
If you or a loved one are seeking low barrier treatment options, our self-empowering outpatient services could be a good fit. Please don’t hesitate to reach out – you don’t have to navigate this alone.