The Trouble with Treatment

Most assessments for substance use disorder are performed by addiction treatment providers. This makes good sense on many levels. Because the addiction treatment is “stand alone” they must market themselves as a solution for that single problem, thus many people self-refer when they or their families believe an individual is showing symptoms of alcoholism or drug addiction. Also many other healthcare and helping professions have happily accepted the idea that addiction and its treatment should be separate and standalone and so they also refer to these separate treatment facilities. The result is that almost everyone who has any training in assessment for SUDs are employed and trained by the addiction treatment industry.
Most often, the first assessment is an admissions assessment. It is designed to determine whether or not the person meets the criteria for a substance use disorder. This is often a requirement for third party payer reimbursement, but it also asks a fundamental and flawed question which is “is this person and addict or not?” The question is fundamental because both the facility and the patient need and want to know whether or not they have a diagnosis of the problem that the facility specializes in. Unfortunately the question (and therefore the assessment process) flawed in many ways.
The Bias toward Diagnosis
Essentially what has occurred is a diagnostic bias that has been created by a unique specialization. If a person self-refers or is referred there is an assumption by all parties that the patient will meet criteria and qualify for treatment. The assessment is “rule in” form this point forward with a possible “rule out” that is almost always based on possible reimbursement issues. If the patient presents and payment is possible, diagnosis becomes assumed and the (unconscious) push is make the criteria fit. While this might be an accurate bias, it is a bias none the less. It therefore introduces and increased possibility of over diagnosis.
The family and all other referral sources for addiction treatment are also subject to bias and prejudice. Usually there has been some large negative consequence of the over use of alcohol and/or drugs. The family strongly desires for there to be a clear diagnosis of the problem and a very clear plan for successful treatment. Addiction treatment has transformed over time to provide the appearance if not the actuality of both.
This leads directly to a very strong intervention bias. Because all stakeholders have agreed or at least acquiesced to the assessment method that is biased toward an either/or outcome. Treatment has then devolved into a single solution for almost everyone who presents at any treatment center after having problems with the over use of mood altering substances. Despite good intentions by all involved, this approach has produced disastrous results in the form of uniformly negative outcome results for patients.