Transforming the US Addiction Treatment Workforce, Part 1

By Tom Horvath, PhD, ABPP

The rapid increase in US overdose deaths in recent years has resulted in increased attention to our drug policies and treatment system. In other developed countries drug policy has increasingly oriented toward harm reduction. Harm reduction approaches emphasize working with individuals who use drugs to increase safe use in the short term, and improved well-being and the resolution of addictive problems in the longer term.

Transforming the US Addiction Treatment Workforce – image of the word change to symbolize transforming the US addiction treatment workforce It’s Needed

This approach has been controversial in the US, on the assumption that any approach that does not insist on immediate abstinence encourages drug use and is therefore counterproductive. This controversy overlooks the reality that in the countries that have embraced a harm reduction approach (for instance, Portugal, Switzerland, the Netherlands) both overdose deaths and addictive problems have decreased. In the US we have embraced ideology over reality, to our detriment. A thorough presentation about the value of harm reduction, and the obstacles to adopting it here, is Undoing drugs: The untold story of harm reduction and the future of addiction, by Maia Szalavitz, published in 2021, which is reviewed here:

Transforming the US Addiction Treatment Workforce – What is Needed

This blog will focus on one aspect of the changes needed for the US addiction treatment system to embrace harm reduction, which is the mindset changes that will be needed in US addiction providers. Most of these providers view addiction as a disease that can only be arrested (not resolved) only by using the 12-step approach. This mindset has worked for many individuals, but in total they are a small portion of those who have resolved addictive problems. Although we do not need to eliminate the disease/12-step orientation, it should be only one option of many that are available to individuals with addictive problems.

Most addiction providers need to adopt the mindset that they are working with their client to accomplish the client’s goals, rather than working against the client’s disease. If you are working against a disease, then confronting the client would seem to be a logical way forward.  “Don’t you realize you have a disease, that you are powerless over it, and that if you don’t follow the 12-step program you are doomed to end up dead or institutionalized? You have trusted your own judgment, and this is where it has taken you. It is time to let go of your own will and be guided by your sponsor, the AA community, and your higher power.” For the client who is willing to adopt this perspective it can be helpful. Unfortunately, most individuals with addictive problems are very far from adopting this perspective.

We also need to consider that many if not most individuals with addictive problems resolve them on their own. Rather than hearing encouragement to move forward on their own (and to seek treatment if not successful) the public repeatedly hears “treatment works” and “you need help.” An alternative way of communicating with individuals with addictive problems is presented here:

If the provider can stop confronting the client, and focus on the client’s goals, one immediate benefit is a reduction in psychological reactance. For most of us, when someone tells us what to do, our nearly instant reaction (the psychological reactance) is to get busy to show them that our freedom has been infringed upon and that we will do what we like. If you tell me “you are the sort of person who is not able to moderate your alcohol consumption” I will most likely set out to show you that I am not that sort of person and indeed I can moderate my consumption. How can counseling or psychotherapy be helpful when the professional and the client are pulling in different directions? The job will be hard enough when they are pulling in the same direction.

We could wait until someone has developed such a deep level of problems, and lost so much confidence in their own judgment, that they are finally willing to be led almost completely by someone else to whom they grant authority. Another expression for this willingness is that the individual has “hit bottom.” Unfortunately, many people die before they experience this willingness, and many could turn around sooner if the cure were not so drastic and disempowering.

Many providers in the traditional addiction treatment community have experienced that “hitting bottom” phenomenon, and therefore they tend to believe that it is essential for change. They typically hope that confronting the client will lead to hitting bottom sooner. This type of confrontation is well-intentioned. Again, however, ideology can over-power reality. One of the most robust findings in addiction treatment (for those who care to review the scientific literature) is that confrontation is ineffective. A review of this literature is here:

The provider needs to become humbler. Rather than thinking that “I know how this change needs to occur,” the provider should be willing to engage in the ongoing exploration, with the client and not against the disease, that will lead to positive change. One of the phrases widely adopted by leaders in the addiction treatment and recovery community is “multiple pathways” of change. Unfortunately, this phrase is not widely implemented. An even more accurate phrase would be “individual pathways.” The professional and client need to work together, over time, typically one small step at a time, to create that individual pathway. Of course, some people change in an instant, or so it seems. In fact, the many small changes that led up to the big change have been overlooked. Alternatively, a catastrophic event could occur (e.g., a health, legal, or relationship crisis) and the individual can instantly reorient themselves. However, the point of addiction treatment is to prevent crises, not wait for them.

To summarize, the changes recommended here, with regard to transforming the US addiction treatment workforce, are to work with the client by focusing on the client’s goals, to recognize that this client has a unique pathway for change that we need to discover together and that we as professionals do not know in advance exactly what that pathway will consist of, and that the process of change may take time and involve many small steps. If this approach is taken it would align itself with how good psychotherapy should be contacted for other problems (e.g., anxiety, depression). That psychotherapy includes focuses on listening closely to clients, recognizing the reality they live in and its impact on them, respecting their autonomy, eliciting their goals and formulating them into workable action steps, and nurturing a treatment relationship where both provider and client are authentic and respectful.

In Part 2 of this blog, I will present specific examples of how individual treatment would move forward based on the foundation described here.

If you or a loved one are interested in experiencing the benefits of transformed addiction treatment, our outpatient services may be a good fit. Please reach out today – you don’t have to do this alone.