Question:
I have some questions related to alcoholism diagnosis and
treatment: Do psychologists see alcohol abuse as a specific
behavior that can be discontinued, or as symptomatic of psychological
problems which must be found and treated before change can be effected?
If an individual discontinues abusive drinking behavior, does a previous
diagnosis of Alcohol Dependency and/or Alcohol Abuse still apply? (If
so, for how long?) Assuming no medical problems (no detox
necessary), what is meant by (outpatient) "alcoholism treatment"? Are
there any standards as to what this treatment should consist of, and
when it should be considered unnecessary? Do assessments/predictions
such as "Relapse Potential Scale" have any scientific validity?
I ask because treatment programs are neither designed nor staffed by
professional psychologists or persons with scientific training, and the
programs seem to be immune to scrutiny or evaluation of efficacy. It
seems to me there is an opportunity for rampant fraud here, particularly
since the "disease model" of problem drinking requires insurance to pay
for anything called "alcoholism treatment."
Answer:
Alcoholism is a primary illness, which is to say that it is not a symptom
of some other problem. However, an alcoholic may have other psychological
problems which can complicate and be complicated by alcoholism.
Depression, for example, or antisocial personality disorder, or an anxiety
disorder, etc. I know quite a few schizophrenics who are also alcoholic.
After years of drinking abusively, many alcoholics begin to develop
cognitive impairments (dementia) which can be irreversible, just as liver
damage, stomach damage, etc. associated with alcoholism can be
irreversible even if the person stops drinking.
Yes. The diagnosis changes to "alcohol dependence, in remission." There
are everal identified subtypes of remission: early full remission, early
partial remission, sustained full remission, sustained partial remission,
etc. It should also be noted that the diagnosis differentiates between
alcoholics with and without physiological dependence; the difference is
whether the individual exhibits alcohol withdrawal syndrome after ceasing
to drink. This usually develops within 24-72 hours.
Alcohol treatment comes in a broad spectrum, including self-help (e.g.,
Alcoholics Anonymous), inpatient treatment (usually 21 or 28 days),
outpatient treatment, etc. In Minnesota it's a growth industry (just
kidding- as HMOs come more to the fore in health care, the rates of people
being treated with inpatient hospitalization is being reduced
significantly).
Are there standards for treatment programs? Yes and no. Programs that
receive Medicare or Medicaid dollars must meet specific criteria for
continued funding. These criteria have force of law and providers that
fail to meet those criteria and continue to bill for services can be
charged with fraud. Programs reimbursed by insurance companies and HMOs
generally are required to meet the criteria established by those payors.
Most hositals also are accredited through an industry organization called
the Joint Commission on the Accreditation of Hospitals (or something like
that). Medicare-eligible hospitals also undergo some kind of inspection
process periodically. Typically the state Department of Health also has
some sort of oversight procedure to monitor the quality of care in
hospitals. Interestingly enough, hospitals work under far less scrutiny
and far fewer regulations than do nursing homes.
The determination of "medical necessity" for treatment is negotiated
between the person doing the assessment and the payor. In most cases,
outpatient alcoholism treatment is associated with similar success and
relapse risk rates as inpatient treatment programs. Outpatient programs
are generally less expensive and are often considered less restrictive
than inpatient programs.
Scientific validity is a different question. There is scientific
examination of such programs in terms of outcome studies, the results of
which tend to be quite consistent. Basically, about 50% of participants
have remained abstinent from alcohol after 1 year, IIRC. Some of the "old
guard" in the CD field have strongly resisted scientific evaluation, since
the AA Steps and Traditions remain the nucleus of the vast majority of
treatment programs. One of those traditions is that AA is a
non-professional self-help group which is not to be run by doctors,
psychologists or other professional helpers.
