On the subject of treatment planning in addictions: I’ve sometimes wondered about our lack of focus. I keep encountering plans that address a whole range of needs that are perhaps real enough but aren’t likely to have much direct impact on ultimate success.

Example from a couple years back: The plan, beautifully composed, included goals related to co-occurring disorders, vocational needs, health status, family problems, and one or two others. All technically justifiable via the assessment, but when ranked in terms of probable impact on the hoped-for outcome– stable recovery and continuation in treatment– only one genuinely stood out. The patient, a 46 year old government attorney, was convinced he did not have a problem with alcohol. Which was unfortunate because by any objective measure, he did. But due to his disagreement, he was unwilling to commit to change. Oh sure, he would pretend a commitment to recovery, but only to placate the powers that be at his workplace.

The clinician acknowledged this in the assessment. Still, most of the time in treatment was devoted to other issues. A psych consult, for example, and a family therapy session with his wife, who had moved out and was already living with another man. Also a career assessment because he thought he might want to change jobs. And a thorough evaluation of his migraine headaches– which by the way, had improved considerably since he finished detox. As an outsider reviewing a record, it struck me that every one of these issues could reasonably be attributed to his alcohol problem– the one he remained convinced he did not have.

I’ve seen a lot of this in recent years, and I wonder if it’s due to the influence of mental health and social service models. A colleague who’d spent a dozen years in psychiatry and another dozen in addictions noted the difference: Mental health approaches emphasize process over outcome– you were evaluated more on how you addressed various aspects of the case, the services you provided and the methods you employed, than on a particular result. Addiction programs, conversely, targeted elimination or at least substantial improvement in substance use– a narrower goal that permitted greater focus in treatment.

Back to that example for a moment: I wondered even then whether treatment hadn’t inadvertently reinforced the patient’s core defenses. It did appear as if he spent sixty days obsessing about other things– his uncooperative spouse, his ‘delusional’ supervisor, his dreams of a new career, even a ‘possible brain tumor’ (his phrase) which he thought might be a factor in his headaches.

When I checked back later, I learned he’d resumed drinking on the flight home. The pilot had considered landing and putting him off, but in the end that hadn’t been necessary.

A few months later, now suspended from his job, he’d called to complain that his costly treatment hadn’t ‘worked’. Couldn’t disagree with that. The outcome might have been the same even if the treatment had been different. But I had a sneaking feeling we’d mostly wasted his time.

What should have happened? Well, IMO, a more single-minded focus on the obvious issue. Doesn’t  matter whether the clinician went on to use MI or CBT or 12 Step or Past-Life Therapy (OK, I’m joking about the last one). So long as the focus was on the one problem most likely to undermine everything else.