The Honour of All is a three-part film about the sobriety movement which began in Alkali Lake, British Columbia, in the early 1970s. The film was made in 1985, approximately 12 years after the community of Alkali Lake began sobering up. Last year, 2010, marked the 25th anniversary of the film, which is still being watched and used in alcoholism treatment centers and therapeutic environments throughout Canada, the United States and Australia.

Part One is entitled, Native Indians: Images of Reality and depicts the experience of Alkali Lake becoming a sober community; Part Two is called, The People of Alkali Lake and reviews the changes that occurred in the community as the result of the sobriety movement. Part Three is known as Innovations that Work. It was filmed during the 1985 International Conference held in Alkali Lake to share recovery solutions with the 1,200 First Nations and American Indians in attendance from around Canada and the United States. This conference was organized by Alkali Lake Chief Charlene Belleau and the Band Council.

In April 1978, former President Gerald Ford and First Lady Betty Ford announced to the nation that Mrs. Ford had sought treatment and was recovering from addiction to alcohol and other drugs. It was a riveting moment in the history of addiction treatment and recovery in America, but the Ford family had further contributions to make to that history. On October 4, 1982, the Betty Ford Center opened on the grounds of the Eisenhower Medical Center in Rancho Mirage, California. When Mrs. Ford sought a leader for the treatment center that would bear her name, she chose John Schwarzlose. Since then, the Betty Ford Center has achieved international esteem under his leadership and has treated more than 80,000 patients (half of whom have been women).

So, the very first meeting, it wound up, oh God, it was a riot. Everybody was fighting with each other. Within two weeks, we only had one or two people left of the original group.

The leaders of modern addiction treatment are disengaging. Long-tenured pioneers in the field have retired or will soon retire. For those about to pass the torch of leadership, it is a time to reflect, teach and mentor. For those into whose hands this torch will be passed, it is a time for preparation. To acknowledge this generational transition, the author has conducted interviews with some of the modern champions of addiction treatment in the United States. This effort will honor these individuals and acknowledge that their work has made a great difference in the lives of individuals, families and communities throughout the United States. This series also gives a new generation of addiction professionals and aspiring leaders an opportunity to learn from those who created the field they now inherit.

This article—the third in a series of articles profiling pioneers of modern addiction treatment—engages two leaders of the international therapeutic community (TC) movement. Dr. David Deitch is one of the most singular figures in the American TC movement and one of the few people whose career transcends the infancy, adolescence and maturation of TCs around the world. Dr. George De Leon has spent a career conducting and publishing scientific studies of TCs, and using the results of these studies to guide the evolution of the international TC movement.

Scientific studies and treatment systems performance data buttress the call to extend acute care models of intervention into severe alcohol and other drug (AOD) problems to models of sustained recovery management (RM) (See White, 2008 for a review). RM models of care focus on service activities across four stages of long-term recovery: pre-recovery identification and engagement; recovery initiation and stabilization; sustained recovery maintenance; and enhanced quality of personal and family life in long-term recovery. Acute care models have traditionally focused only on stage two.

Pilots of RM in the United States reveal substantial changes in mainstream clinical practices, including:
• assertive outreach and engagement, recovery priming, expedited access and therapeutic engagement;
• improved (global, strengths-based, continual) systems of individual, family and community assessment;
• an expanded multidisciplinary team that includes greater integration of primary medicine, addiction medicine, addiction psychiatry and indigenous peer-based recovery support services;
• a shift in the service relationship from that of the hierarchy of the expert-to-patient encounter to that of a sustained recovery partnership model;
• enhancements in the scope, quality and duration of addiction treatment, with an emphasis on continuity of contact over time in a primary recovery support relationship;
• broadened locus of service delivery, including home- and neighborhood-based service delivery and co-location within indigenous non-stigmatized service sites (health clinics, community centers, churches);
• assertive linkage of individuals and families to communities of recovery and new recovery support institutions (recovery homes, schools, ministries, industries, social clubs, etc.);
• an emphasis on post-treatment monitoring and support, stage-appropriate recovery education, and if needed, early re-intervention services for all admitted clients/families for up to five years following completion of primary treatment; and
• the systematic collection of long-term, post-treatment recovery outcomes for all clients/families admitted to addiction treatment programs (White, 2008).

The focus of recovery management is to proactively manage the prolonged course of addiction and recovery careers rather than focus on what all too often end up being serial episodes of biopsychosocial stabilization. The following discussion will explore the evolution of the modern TC and what the emerging philosophy of recovery management will mean for the future of the American TC and other residential programs that have been profoundly influenced by the TC movement.

Therapeutic communities

Bill White: David, let me begin by asking you to introduce yourself to our readers and summarize the birth and early evolution of therapeutic communities (TCs) in the United States as you witnessed it?

David Deitch: It’s a delight to participate with you and George to reflect on the evolution of the therapeutic community. I come to this discussion with a lengthy history of over 60 years in the addiction world. My first education was regrettably my early use of heroin, which I began at the age of 15. In 1951, I was arrested for drug possession and entered addiction treatment at the federal prison/hospital in Lexington, Kentucky (known as “the farm”). Upon release, I finished high school and became excited about learning, particularly philosophy and psychology. I continued sporadic college education amidst a continued cycle of relapse, crime and arrest. I was unable to get it together in spite of multiple treatments. At each institution, I tried hard to understand what was wrong with me. I attended every group, had great and caring psychiatrists, but always relapsed upon my return home. Then in 1961, I left New York in search of a new rumored “cure” called Synanon in Santa Monica, California.

Synanon was the beginning of the American TC movement and my first exposure to peer-based mutual help. It had everything—a charismatic leader, colorful ex-cons, con artists, motorcycle gang members, great jazz musicians, liberated women. We (recovering addicts) did everything, including security. Everybody started at the bottom and earned their way up. It wasn’t a treatment program; it was an amazing community, and every­one contributed to its magic. Synanon was a new society that honored the outsider, played to the rebel. It was a place where we entered to get clean and ended up seeing ourselves as the heroes of a new movement. These were the days before Synanon evolved into a cult and eventually imploded.

Many of us who left before Synanon developed into such a closed community were called upon by different agencies to help start new therapeutic communities. Daytop Lodge was the first. The lead psychologist for the Brooklyn Department of Probation, Alex Bassin, and the Chief Probation Officer, Joseph Shelly, visited Synanon and embraced it as an answer to the growing heroin problem in New York. They sought funds from NIMH [National Institute of Mental Health] to place addicts on probation into a Synanon-like setting and recruited me to develop that program. In 1965, we, along with Monsignor William B. O’Brien, formed Daytop Village. Daytop Village marked a break from Synanon and set the model for future TCs in terms of acceptance of government funding, evaluation procedures and external governance.

1965-1970 in New York was a breeding ground for TCs due in great part to the influence of Dr. Efren Raimirez, a psychiatrist recruited as New York City’s first “drug czar” by Major Lindsay. Efren, who had been trained in the Maxwell Jones TC model, persuaded me to use the term therapeutic community (TC) as a more scientific way to describe our method. Until that time, we had proudly used the term, “A Humanizing Community.” Efren hosted regular meetings of key people interested in the treatment of heroin addiction. These meetings included Mitch Rosenthal, who developed Phoenix House; Judy Densen-Gerber, who founded Odyssey House; and a young social worker, who helped create Samaritan Village. Within a few years, Daytop graduates went on to help build Gaudenzia in Philadelphia, Gateway in Chicago, Walden House in San Francisco, and Marathon House of New England. By the 1970s, a full fledged TC movement was spreading across the United States, Europe and Asia. TC methods became more diverse across these different geographical, cultural and political contexts. Since this period, I have had the privilege of observing and participating in the worldwide spread and evolution of the TC as a treatment for addiction.

Bill: Thanks, David. George, could you introduce yourself to our readers and add your thoughts on the early evolution of the TC movement?

George De Leon: As a jazz musician, years before my career as a psychologist, I understood the drug problem through its impact on friends and fellow musicians, some of whom turned their lives around in Synanon. I had early contacts with Daytop Village and Synanon groups in New York, but my work in the TC movement began when Mitch Rosenthal asked me to bring my research skills to help in the development of Phoenix House, circa 1967.

The powerful transformational effects of the TCs on individuals that I observed as a psychologist convinced me that the acceptance and advancement of this approach depended upon supportive research. Our first investigations were to understand the treatment process and are described in a now out of print volume (De Leon, 1974). However, research quickly shifted to establish the credibility of the TC through outcome studies. This resulted in a 1973 publication in the Journal of the American Medical Association of our initial report on the relation of time in the program to post-treatment reductions in criminality and drug use. The development of the TCs in general, and research in particular, led to the first national conference on TCs in 1976, funded by NIDA [National Institute on Drug Addiction], which I coordinated. A conclusion in the Proceedings of that event appears prescient today in 2009: The TC’s evolution may be characterized as a movement from the marginal to the mainstream of substance abuse treatment and human services. Unlike its communal prototypes which have disappeared in history, the TC is a hybrid spawned from the union of a grassroots self-help movement and the rise of publicly supported addiction treatment. As a mainstream modality, today, the TC contains a profound and paradoxical threat—the loss of the unique self-help identity that has defined its success (De Leon & Beschner, 1977).

Bill: What do you see as the most significant changes in the TC since its inception?

George: Today, the TC modality consists of a wide range of programs serving a diversity of patients who use a variety of drugs and present complex social-psychological problems in addition to their chemical abuse (see De Leon, 1997; 2008). Patient differences as well as clinical requirements and funding realities have encouraged the development of modified residential TCs with shorter planned durations of stay (three, six and 12 months) as well as TC-oriented day treatment and outpatient ambulatory models for cocaine and methadone maintenance clients. Correctional, medical and mental hospitals, as well as community residence and shelter settings, overwhelmed with alcohol and illicit drug abuse problems, have implemented TC programs within their institutional boundaries. A wide variety of practices and interventions have been incorporated into the basic TC approach to address the diversity of client needs and profiles. These include, for example, pharmacologic adjuncts for substance abusers with serious non-drug psychiatric diagnoses as well as evidence-based non-medical interventions, such as motivational interviewing, relapse prevention training, cognitive behavioral strategies and family therapies.

David: One of the most significant areas of change involves TC policies towards alcohol and the TC relationship with Alcoholics Anonymous (AA) and other community-based support groups. Dederich, Synanon’s charismatic founder, deliberately distanced Synanon from AA and NA. Early members of the TC movement had no idea of the history, Steps, and traditions of these fellowships. Some early TCs developed drinking privileges that could be earned as one matured within the TC. But the reality was that alcoholism began to degrade and kill ex-addicts within the TC community who had influence, energy, and promise as future TC leaders. There was also a larger schism in the field in how alcoholics and opiate addicts were viewed—stereotypes that kept the fields separate for a number of years.

Coming to grips with alcohol as a TC issue and moving toward integrated treatment of multiple drug dependencies occurred at a time the TC was trying to define itself amidst powerful outside influences. Members who emerged as leaders (once public funding was part of the mix) then became staff. The concept of elders and change-agents slowly gave way to career paths and government regulation and demands for professional certification and licensure. Present but dwindling was the belief that modeling recovery remained a critical component of the TC-guided process of recovery. The emergence of the TC as a professionalized movement in the 1970s was a painful process.

Bill: What was distinctive about the TC? What philosophies and practices historically separate the TC from all other addiction treatment modalities?
David: To begin with, the TC was, in its earliest stages, completely consumer driven. These consumers shaped its methods, philosophies, business practices, and pushed the whole person focus—different individuals’ talents led to new activities, which were then incorporated into practice. Secondly, it remained un­usually responsive to the “in the trenches” social problems that were becoming evident in the second half of the twentieth century. For example, TCs were on the front lines in working with HIV and AIDS in non-medical settings, and again, it used those very consumers to help guide and create services for this population. The same was true with homeless and then transgender populations. Each of these consumer groups helped construct services in the TC that were relevant to their needs.

Now admittedly, this adaptability can still be time and culture tied and as such, some TCs became rigid with outdated and questionable practices. This has created and continues to create both confusion and tension in the field. From the perspective of recovery-oriented treatment, the early TC format developed by consumers considered itself as the treatment plan (i.e., all people in it needed the same exact thing). Once it was considered a model deserving of funding, the funders demanded aspects of models they were familiar with—principally, the medical model—
and as such, they wanted features such as treatment plans. While this was initially viewed with dismay, it led the way for new consumer driven adaptations like those mentioned above. The most lively and current adaptation is working with a wide variety of psychiatric co-occurring difficulties. This challenge has helped foster trans-disciplinary treatment plan development, which, unlike medical and other addiction treatment models (multi-disciplinary), always keeps the whole person front and center. Every person on the team, including other client members, is made aware of what problems are paramount (first things first) and brings appropriate attention to the problem. This has brought a re-evaluation of the TC’s early rejection of medications and a change in the early view that so-called “psychiatric issues” were an excuse and cover for people to escape personal ­accountability.

George: Arguably, the therapeutic community for addictions (TC) is one of the first formal treatment approaches that is explicitly recovery-oriented. Surely, AA and similar mutual self-help approaches facilitate recovery, but these represent themselves as support, not treatment. Pharmacological approaches, notably, methadone maintenance, have historically defined their treatment goal as the reduction or elimination of illicit opiate use. Evidence-based psychological approaches, such as cognitive behavioral therapy (CBT), contingency contracting and motivational enhancement (MET) focus upon reduction in targeted drug use. In the TC perspective, however, the primary goal of treatment is recovery, broadly defined as changes in lifestyle and identity reflected in abstinence from all non-prescribed drug use; elimination of social deviance; and development of pro-social behaviors and values (De Leon, 2000). Thus, what distinguishes the TC is its recovery-oriented perspective guiding a unique social psychological approach—community as method—which is designed to address changes in the “whole ­person.”

Bill: What changes in TC practices do you feel were positive stages of maturation of the TC, and what changes do you feel may raise concerns about the integrity of the TC model?

David: The TC model must remain open to new problems and to new or better ways of handling complex problems. We know more now than ever before, but there’s a lot more to learn. For example, the knowledge regarding brain adaptation to chronic drug use has helped us better appreciate craving and relapse. Reward seeking behavior is a fact of human existence and for many drug users, particularly those at end stage addiction, there are very few (if any) reward sources left but drugs. For this population in particular, any pharmacotherapy that can reduce craving is a step we must take to help open and sustain a recovery pathway.

The long-standing myth that an intervention, regardless of model type or duration, can provide a “cure” is over. To gain social approval, acceptance and funding, TCs had to both buy in to the claim that they (and usually only they) could provide “cures.” I think most treatment models, including the TC, now recognize that recovery does not occur as a result of the TC stay, but rather, we are there to start the recovery process.

George: We’ve summarized above a number of broad developments in the evolution of the TC. However, advances in specific TC practices, though not uniformly incorporated in all programs, mark the maturation of the TC as a sophisticated treatment approach.
As David mentioned, we have witnessed the inclusion of medications in the TC treatment regimen. The key development here is the gradual rapprochement between the TC “drug free” and the mainstream medically assisted/mental health perspectives. Examples include psychotropic medications for substance abusers with serious non-drug psychiatric diagnoses and the integration of bupre­norphine and methadone into specially modified TCs. TCs have been adapted for the seriously mentally ill, adolescents and juvenile justice and criminal justice clients, and now incorporate evidence-based practices, which are relevant to the special needs of these populations. This reflects TCs’ growing respect for individual differences.
The earlier adherence to a rigid view of individual change is altered in contemporary TCs. There is, for example, more flexibility in discharge and readmission policies. Dropout is no longer viewed as clinical failure but as an issue of motivation, readiness and suitability for TC treatment. Family involvement has also dramatically changed within the TC. Contemporary TCs accept the importance of family/significant other involvement in the treatment of the client. They have incorporated a range of family therapy, education and social activities aimed at sustaining client participation in treatment and enhancing family health.

It is also noteworthy that TCs have abandoned questionable and harsh practices (e.g., shaved heads, stocking caps, wearing signs or baby diapers, employing toothbrushes (for cleaning urinals)). These were rationalized as useful strategies for some clients in addressing the immaturity and social deviancy features of their disorder. Such practices were largely abandoned by the 1980s and are now prohibited by policy in contemporary TCs. (It should be noted that while harsh practices were unnecessary and appropriately abandoned, there is no compelling statistical or clinical evidence that they resulted in harmful outcomes.)

Bill: Could you both elaborate on fears you have about this loss of integrity of the TC model?

David: My principal worry about TC as a model is that treatment business needs and escalating regulatory demands conjointly erode the model. We already have seen cost-efficiency motivation result in utilizing large facilities—200- and 300-bed institutions—which then, due to size and logistic management, end up (as a result of efforts to find efficiency) sacrificing interactive healing methods because they take too much time.
George: The adaptation of the TC to serve special populations in special settings, the diversity of staff composition, and the utilization of evidence-based practices all illustrate the remarkable flexibility of the TC. However, this evolution has been at the expense of advancing the TC as a unique social psychological model. What I am stressing here are three interrelated negative developments: the incremental drift away from implementing essential elements of the TC model; the incorporation of evidence-based practices and social services to substitute for rather than enhance community as method, the primary treatment element; and specifically, the abandonment of research and clinical efforts to refine and improve community as method.

TC research findings
Bill: George, you have spent much of your career researching the effectiveness of the TC. What conclusions can be drawn from this research to date?

George: Over 40 years of research has generated a considerable knowledge base concerning the effectiveness of the TC approach. The TC’s role in initiating long-term recovery outcomes is documented by the weight of research evidence from multiple sources, including multi-modality and single program field effectiveness studies conducted worldwide that involve thousands of individuals followed up to 12 years post-treatment; statistical meta-analyses involving comparative studies; a small number of randomized control studies; and by indirect evidence from social psychological studies supporting basic elements of the TC model.

Significant numbers of admissions to TCs reveal positive outcomes in: reduction of drug use; reduction of criminality; increased employment; improved psychological status and quality of life; and reductions in medical and mental health expenditures. These personal outcomes of TC involvement obviously have significant cost benefits to society. Retention in treatment is the most consistent predictor of TC outcomes. Generally, the longer the stay in treatment, the better the post-treatment outcomes.

The evidence is compelling that the TC is an effective treatment for a certain subset of substance abusers. Those who benefit most display severe profiles in terms of substance abuse and associated social and psychological problems. Treatment effectiveness with these difficult populations is strongly associated with fidelity to the TC model. Fidelity can be maintained with standards for program certification, appropriate fidelity and quality assessment methods, relevant staff training models and curricula, which result in credentialed TC professionals. Aftercare is also essential to the stability of treatment effects. As planned duration of residential treatment decreases, there is a necessary increase in the range of outpatient recovery-oriented treatment and social services that TCs are offering.

The above asserts that the TC approach is effective for certain substance abusers and does not claim superiority or cure. Moreover, drop­out is the rule across the major treatment modalities and analogously, the rates of non-adherence to medications for diabetes and hypertension is similar to the dropout rate for substance abuse treatment (McLellan, Lewis, O’Brien, & Kleber, 2000). Further, the time in program effects for TCs are reported almost universally, which underscores positive outcomes for many who do not complete treatment or enter the field. The effectiveness of a treatment should not be confused with retention, which remains a general problem in health care.

David: I am also uncomfortable with the claim that one major addiction treatment modality is superior to another. There is little evidence to support this, and I think such claims feed the social expectation that one approach offers a better “cure” than another model. TC approaches have critical and important dimensions that do help a number of people and yet fail to help others—a point that is evident if we look at the TC retention rates. Those for whom the TC is ill-suited are voting with their feet. Many of George’s early studies include people staying clean as a result of their new social definition as helpers and the social status of the TC as a new modality—our early expansion years. The newly defined ex-addict staff didn’t pay much attention to those who left and in fact, condemned them as losers. We viewed ourselves as cured and failed to ­realize that the source of our recovery maintenance was the fellowship of mutual help and support that came from our sustained connection with the TC. The cure was such an important part of our belief that when relapses occurred, they were hushed up or denied.

While George and I agree on most things, especially those related to improving practices in TCs, I think it’s important to recognize how much TC outcomes and practices vary from program to program, particularly across American, European, Asian, African and Latin American contexts. Furthermore, what is considered community as method (as powerfully delineated and written by George) was principally formulated on practices in North America and from the early 70s and 80s when the TC movement was a new, romantic and powerful political force in New York. George’s work is far more sophisticated and aspirational than practices within far too many TCs that remain unproven and potentially harmful.

Thirdly, the characterization of the problem as a problem of the whole person is essentially derived from early TCs, which referred to the problem as “character disorder”—a new descriptor developed in the 60s as more enlightened than “weak moral character” or “sinner.” But even this new term created a pejorative, dehumanizing, stigmatizing view of the person seeking help for addiction. It contributed to staff in TCs and other treatment modalities in the early 1970s treating individuals in their care with contempt and control—that “my way or the highway” attitude. Those tough tactics were congruent with “the kick in the butt” that so many in the culture saw addicts as needing. Eventually, the TC evolved five areas of focus that distinguished the TC from other modalities: behavior shaping; emotional and psychological life; intellectual, spiritual and ethical life; vocational and social survival life; and finally, bio-medical activity.

Bill: What are the most important questions yet to be answered about the effectiveness of the TC?

George: David’s comment raises a brief point of clarification. Early descriptions of the addict often referred to personality or character disorder. Diagnostic studies generally confirmed these descriptions in showing a prominence of Axis 2 categories (e.g., anti-social personality and to a lesser extent, narcissistic and borderline personalities). However, the term “whole person” was adopted to reflect the common clinical observation supported by research that substance abusers in TCs display a multidimensionsal disorder, including cognitive, emotional and behavioral problems, all of which must be addressed to initiate a recovery process.

There is still skepticism among some critics concerning the cost benefit of the TC given the relative lack of randomized, double blind control trials. This and other related questions define a new research agenda for the TC. First, we need randomized controlled trial studies, but these must by guided by the complexity of the TC approach. Second, we need research on how to improve the TC in such areas as engagement and retention, accelerating clinical progress, and isolating the relative effectiveness of program elements. In particular, community as method is a powerful approach that needs to be better understood and refined to realize its potential. Third, research is needed on appropriate models for staff training in the TC approach. The increase in traditional mental health, human services and correctional professionals in TC staff compositions requires effective training models that assure fidelity in implementing community as method.

David: Unlike George, I do not think we have, as yet, TC research that thoroughly examines if length of stay matters. I think that without experi­mental design, random assignment, and controls, the model will still provoke skepticism. Permit me one example: most researchers have concluded (as has George) that a minimum dose of at least 90 days participation is necessary to create some recovery direction. If we closely examine TC retention across the board nationally, we see that by day 30, we generally have lost 25 to 30 percent; by day 90, 30 to 40 percent; and by 120 days, about 50 percent. The only exception to this that I know of is when LOS [length of stay] is clearly described as short-term treatment—where, to the best of my ability to rationalize, people stay longer because they can see light at the end of the tunnel. Yet most TCs behave as if their members are going to stay considerably longer and frequently plan treatment content and sequence on this paradigm. Secondly, even when mandated to care on an average of six months as we have seen in “in-custody” TCs across the nation, once the halo effect—of initial enthusiasm, new social work role and definition for the first wave of treated “ex-cons”—wanes, outcomes plummet.

My thinking is we need to seriously examine length of stay in the context of what is provided and when.

George: The relationship between retention and outcomes has been demonstrated in the major treatment modalities, including TCs, implying a “dose” related effect. In general, we can say that more is better. Also, clients mandated to community-based TCs show similar findings to “voluntary” clients, relating longer time to positive outcomes. The studies of prison-based TCs also support the time in program effects obtained in community-based populations. For example, completion of 9-12 months of prison-based treatment followed by six+ months of TC aftercare in the community produces significantly reduced recidivism and drug use (see Special Edition: Drug Treatment Outcomes, 1999) compared to prison-based treatment alone. It is true that most completers of prison TCs do not elect aftercare, which underscores the importance of the above issues of motivation and engagement. Length of stay has always served as a proxy for dosage, that is, for time-correlated treatment activities. It is not time alone, but engagement in these activities that facilitates individual change (De Leon & Wexler, 2009).

Recovery management and the TC

Bill: RM calls for the historical reversal of the decreased duration of treatment across levels of care sparked by an aggressive system of managed behavioral health care. Do you see a day when treatment dose is extended beyond what have been ever-shortened lengths of stay?

George: Reductions in planned duration of (residential) treatment in the early (acute) stages of recovery have resulted in extending the period of continuing care or aftercare. In the best cases, TCs have adapted to this change in several ways: formulating more realistic goals for the shorter time in primary residential treatment; better assessment of individual differences as to the need for residential treatment (matching); and developing firmer links with aftercare resources, including greater involvement with 12-step groups.
In a recovery-oriented framework, individuals learn to use the challenges of daily living in natural environments to advance incremental change in their recovery. The key issue for TCs is to prepare the individual for those challenges within shorter planned durations of primary treatment. This means that individuals obtain a “threshold dosage” of treatment to achieve early to mid stage recovery goals. These emphasize their commitment to utilize aftercare treatment as well as social and community re­sources of the system to facilitate their continued change process.

David: Depending on drug use and mental health severity, social and vocational resources are the key factors for us to consider in type of placement and initial duration. Regardless, what will count is the value of the exposure in terms of content and sequence—and this is best responded to by validated assessments that can measure needs and measure whether what we are practicing is actually effective.

Bill: A recovery advocacy movement emerged in the early 2000s that exerted a major influence on calls to shift addiction treatment toward a model of sustained recovery management (RM). These advocates argued that addiction treatment, through its professionalization and commercialization, had become disconnected from the larger and more enduring process of long-term recovery and that addiction treatment had become too isolated from local communities. Do you feel those are apt criticisms of the modern TC?

David: I absolutely do think these criticisms are overdue and accurate. As I mentioned above, the claims for cure and uniqueness and supposed competitive gain meant that (early) TCs viewed themselves as a single event intervention (with regards to duration). The TCs fixed the problem. Early concepts of service, community building, fun and vibrant alumni helping to sustain the TC were slowly lost. Careerists replaced “change agents.” Staff counselors replaced careerists, and licensing or certification and funder demands created commercialism. TCs were developed as alternatives to big costly bureaucratic institutions. They are now big businesses, highly bureaucratic, but still less costly—but something had to go: service to community, humility, time consuming interactive healing practices, and a good bit of “counselor” enthusiasm as those on the front line became inundated with management and regulatory demands.

The recovery movement is timely, necessary and has already provided a boost to TCs fortunate enough to work in proximity to active recovery management groups.

George: A disconnection from the recovery process by TCs is also evident but relates to broader issues that include the professionalization and commercialization of addiction treatment. In the evolution of the substance abuse treatment system, support has been inconsistent for recovery-oriented approaches in general and for TC programs in particular. This reflects policy and ideological issues that have disconnected the TC from the process of long-term recovery. 

Funding pressures have dramatically reduced the planned duration of treatment, often below threshold levels of time needed to initiate a stable recovery process. This policy contradicts the science documenting the relationship between retention and recovery outcomes in both community and correctional TC studies.

The contemporary call for evidence-based strategies has focused upon treating specific behaviors, such as drug use. This contrasts with ­evidence-based programs, such as TCs, which are multi-interventional approaches designed to address the multidimensional “disorder of the whole ­person.”

The fidelity of TC programs has declined in part as a reaction to these various issues. Efforts to shorten program duration to treat serious abusers engenders less favorable outcomes; the incorporation of various evidence-based strategies (e.g., Cognitive-Behavioral therapy [CBT] or motivational enhancement [MET]) while useful, has substituted for rather than enhanced the active ingredient of the TC community as method.
As TC agencies have strived to fit into mainstream medical/mental health/human services frameworks and to compete for and comply with contract requirements, regulations and funding priorities, they gradually have drifted from their missionary goal to advance long-term recovery to that of managing disease.

Bill: Advocates of RM are calling for substantial changes in service practices within addiction treatment. Some of these recommendations have a historical mustiness about them. Do you see any of the early TC in these recommended changes?

David: I certainly see an enthusiasm, a zealotry and emerging orthodoxy in its claims very much like early TCs. But that’s okay; it’s provoking new thinking for all of us.

George: I agree with David’s characterization of the recovery phenomenon as similar to that of the early
TCs. More specifically, TCs always stressed that sustaining recovery must include key elements, such as drug free peer networks for support and informal counseling; reintegration with healthy families; and constructive use of mental health and human services.

Bill: Perhaps we can further explore how some of the RM practice changes will affect the future evolution of the TC. Let’s start with the issues of attraction and engagement. The RM model calls for assertive community outreach; lowered thresholds of engagement; and a focus on enhancing treatment retention rates. How do you see the status and future of American TC practices in these areas?

George: The RM approach must acknowledge the proposition that the population of substance abusers varies in severity of substance abuse disorder, psychological health, life­styles, and habilitation. For certain subgroups of substance abusers, a residential 24/7 TC will be necessary to initiate a recovery process. For these individuals, the TC has struggled with the issues of attraction and engage­ment, particularly since it is viewed as a high demand treatment (which is appropriate for a high severity client). Admission and clinical practices have altered to increase.

Science has served as a powerful tool to elevate the quality of modern addiction treatment, and there is no name more associated with that effort than Dr. Tom McLellan. Dr. McLellan served as Professor of Psychology in Psychiatry at the University of Pennsylvania, developed the Addiction Severity Index, authored more than 400 articles and chapters on addiction treatment, founded the Treatment Research Institute (TRI), and held the position of Editor in Chief of the Journal of Substance Abuse Treatment. He currently leads demand reduction efforts at the White House Office of National Drug Control Policy (ONDCP). His persistent and eloquent voice, challenging the field to fundamentally rethink how addiction treatment is designed and evaluated, has earned him innumerable awards from professional societies in the United States and Europe.  In this wide-ranging interview, Dr. McLellan explores his career and what he has learned from his studies about addiction treatment and the role of the addiction counselor in treatment outcomes. He also shares his thoughts about the future of addiction treatment and how he has sought to influence that future through his work at ONDCP.    

Bill White: Tom, you’ve spent your career wrestling with questions of great relevance to frontline addiction professionals. What circumstances led to your pursuing research on addiction treatment?
Dr. McLellan: Well, like almost everybody I have ever met who has been a career addiction researcher, I didn’t start out with this intent. I, like most people, had a different idea in mind. I studied psychology, but not clinical psychology. I was a rat runner and an animal learning guy with a background in physiological psychology, and that’s what I intended to do. When I got out of graduate school, there weren’t any jobs, but circumstances permitted me to buy a small farm in central Pennsylvania. I looked around for a job, and the closest one was the Coatesville Veteran’s Administration Medical Center. I went down there equipped with a degree in animal learning and nothing else, and surprisingly, they had no jobs for anybody with an animal learning degree. They did have a job as a Research Technician at that time (1975) in an emerging area of interest for the Veteran’s Administration: treating addiction in returning Vietnam-era veterans. I became enamored of the whole field the first time I walked into a therapeutic community. There were guys my age. They looked like me. They had the same background I had. I knew nothing about addiction, and nothing in my academic training prepared me for anything of it, but I immediately found it really interesting.

Bill White: One of your early interests there was the relationship between patients’ drug choices and particular types of psychiatric disorders. How did that interest develop?
Dr. McLellan: Well, once again, there was no planning involved. I was a junior faculty member at the Coatesville Veteran’s Administration Medical Center. At that time, they had about 3,000 residential beds that were constantly filled with people who had psychiatric illness, really quite severe psychiatric illness. This was the era of the first patients’ rights movement, and it fell to me to evaluate a random sample of patients and ask them confidentially about their satisfaction with all manner of things, like their treatment, the food, the doctors and all of that. Well, in the course of this, I was able to insert some additional questions about whether there had been any drug use in their history. And indeed, there was. More importantly, many of them were actively involved in using alcohol and other drugs right on the campus. I was amazed by that—showing my naïveté—so that was the first report; but the second report was a little more interesting.

Because I had interviewed these individuals without any kind of background, I later went and looked up their diagnoses. It turned out that their diagnoses were quite related to the kinds of drugs that they had been using. People who were diagnosed as depressed were often using a variety of depressant or tranquilizing drugs. People who were diagnosed with schizophrenia had histories of using amphetamine—there was very little cocaine use at that time. The people with alcohol and opiate use backgrounds had a variety of diagnoses. I wrote an early paper on this possible relationship.

This led me to ask such questions of current patients, many of whom had been coming to the Veteran’s Administration for a number of years. By tracing back their early psychiatric test results, I found over a six year period, in a sample of people who had returned to treatment every year for six years, that there was a progressive development of psychiatric problems that mirrored the actions of the drugs they were using. Particularly interesting were the changes in psychiatric diagnoses among people who used amphetamine/methamphetamine over a six year period. They moved from being treated primarily in the drug unit, to being treated in the psychiatric unit, and finally, into locked wards. It looked as though, after some period of time, the symptoms that were purely drug-related and temporary ultimately ended up being permanent or semi-permanent. The same thing happened with people who used combinations of alcohol and depressants. Depression—significant, serious depression—was sustained. Also interesting, we saw no major changes in the psychiatric problems of people who used opiates or alcohol.

As a point of potential interest to young researchers, I wrote these findings and tried to present them to the American Psychological Association, and they turned it down flat. A friend of mine said he thought it had some medical interest, and it was later a lead article in the New England Journal of Medicine. So, for young people who are starting out, don’t get too worried if you get a rejection. The other point of interest is that much of what I’ve learned and done was not achieved through planned studies and experiments, but by being in a clinical situation and keeping my eyes open and listening to the clinicians and especially to the patients.

Bill White: That reinforces for our readers the importance of observation and reflecting on those observations.
Dr. McLellan: Yes. Today, I’m in a policy office and haven’t had patient contact for several years. I miss that very much. Very selfishly, if you don’t have direct patient contact, it’s very difficult to come up with sensible, relevant clinical ideas.

Bill White: Many of our readers at Counselor know you through your work developing the Addiction Severity Index. When you look back over the years since its original development, what are the most important things you have learned about the process of clinical assessment?
Dr. McLellan: There’s a real theme emerging here. The Addiction Severity Index was completely unplanned. It was born entirely of clinical necessity. I was working in a residential therapeutic community, and every patient who came into treatment was clinically staffed. Staffing meant that you had—boy, these are the old days—a psychiatrist, a psychologist, a nurse, a counselor, a social worker, an employment counselor and someone from administration. Every person who came in sat at the end of a table after they stabilized and were interviewed by all of these people from the various service areas. I was asked to develop something that would be easier and faster than this rather grueling 90-minute process. So, I tried to distill the questions that had been asked by those various service representatives into questions that could be asked by somebody with far less training. I had two goals in mind: 1) getting an initial assessment of the severity of the various kinds of presenting problems; and 2) developing a sort of screen through which this initial assessment might lead to more detailed professional assessment.

So being very proud of myself, I showed it to the clinical staff.  They didn’t like it one bit, primarily because it was filled with numbers, and the numbers couldn’t really translate into something that they were used to—a nicely written, professional admission note and a treatment plan. So I said, “You don’t want a researcher without a lot of clinical experience doing a treatment plan, so suppose I just summarize the information in each area into a single severity as a single number?” And that’s what I did.  I had already named it the Addiction Severity Index because I fully expected that all of the problems—the employment, the legal, the medical, psychiatric, etc.—would be the direct result of the severity of the drug use. Well, I was amazed to find that that was not the case.

People with the most severe drug problems often did not necessarily have the most severe employment or psychiatric problems. People with really severe psychiatric problems, for example, often did not have severe drug problems. I had named it an “Index” because I thought we could add up all the numbers into one single number, but that was clearly not possible given what we were finding. But more importantly, it suggested to me from the very beginning that “addiction related problems” can be related in very different ways. Some problems cause substance use; some problems result from substance use; and some simply emerge along with substance use as the result of genetic, personality or environmental conditions. This was one of the most important things I ever learned about addiction. Like many of the people I meet in my current job, I too thought that if you just reduce the drug use, all the other “drug related” problems would disappear. This was, and still is, a very naïve view. Worse, it has been a very big force in the way the original—and some of the existing—treatment programs were conceptualized, designed, funded and evaluated.  

Bill White: You have challenged the field to make addiction treatment more attractive and engaging. How might addiction professionals working in local treatment programs contribute to that goal?
Dr. McLellan: I do think treatment has to be more engaging, but I also have to first say that it’s quite easy for a guy who’s sitting at a desk here
in Washington to start making pronouncements about what clinicians working every day with very difficult patients ought to do. I do know that none of what I am about to say is easy to do.

I’ve spent my whole career looking at all of the kinds of things that have been tried—at least in this country—to reduce substance use problems, and treatment is by far the best. So, my whole goal from early on has been to find ways of getting more people into treatment and keeping people who are already in treatment, in treatment longer. With that proviso, let me begin by saying that the nature of most existing addiction treatment has not been particularly attractive to most of the individuals who could benefit most from it. That is not my opinion; that is just simple fact. We have between 23 and 25 million people with diagnosed substance use problems in the country, and on any given day, there’s maybe 2 to 2.5 million of them in treatment. So, only one-tenth of those with a diagnosed illness are receiving care. More importantly, that 10 percent is by no means representative of the rest of the 25 million people. They’re the most severe. They’re the most chronic and difficult. Most of them have been forced into treatment. Further, they’re in treatment that is typically segregated from the rest of healthcare. So I don’t see this as the best way to attract more people into treatment or to keep patients in treatment longer.  We have to find ways to make treatment more attractive and effective for this larger population.

Bill White: Tom, do you see a day when addiction counselors will be working in a wide variety of settings outside of specialized addiction treatment?
Dr. McLellan: Yes, I do. In this policy environment that I’m in now, one of the emerging themes is integrating addiction treatment into mainstream healthcare. I know a lot of readers are going to get very worried about that. They know the bad old days when addiction was treated under the mental health umbrella and was viewed as merely a symptom of an underlying depression or personality disorder and never given the emphasis it properly required. I hope that doesn’t come back, but here’s the other truth: addiction treatment as a field is currently reaching only a tiny fraction of the people it should reach.

Addiction is causing and is complicating a lot of medical disorders. Mainstream healthcare has never really paid the attention it should have to addiction related problems in the mainstream healthcare system. Meanwhile, as addiction treatment has become more segregated, budgets have been reduced virtually every year since I’ve been working in this field. I know of no kind of treatment, education or public enterprise that is best when it is segregated. So we’re trying very hard to bring addiction treatment—particularly screening and early intervention with mild to moderate substance use disorders—into lots more healthcare settings, particularly primary care and family medicine centers. Importantly, I am talking less about “addiction,” than about the less severe and less chronic forms of substance use—unhealthy use, problematic use, etc.  We’re trying to develop more and more varied kinds of treatments: treatments that will involve medications, treatments that will involve families; treatments that will involve whole communities. We are hoping that different types of treatments for mild to moderate substance use problems, delivered within the same context as the rest of medical care, are more attractive and engaging to those who will not even consider treatment now.

And if you’re wondering if I’m ever going to get around to answering your question, in every one of these environments, there is a need for workforce. Certainly physicians are not going to do this alone. Nurses, counselors, psychologists and social workers are going to be needed. Behavioral health disorders so complicate other health disorders that all of these conditions need to be treated in an integrated fashion. So, we need more counselors and other behavioral health specialists ready to rise to this challenge. Tomorrow’s counselor is going to need to know a lot more about medicine, a lot more about genetics, and a lot more about case management. It will be a quite different role in the coming years.

Bill White: One of the questions that you’ve researched that will be of great interest to the readers of Counselor is whether the counselor is an active ingredient in addiction treatment outcomes. Could you summarize what your research revealed on this question?
Dr. McLellan: The research that I did on counseling was among the more interesting chapters in my professional life. Once again, it started in an unplanned way. I was, by this time, working with George Woody and Chuck O’Brien at the Philadelphia VA Medical Center in a large methadone treatment program. Two counselors, each with a very large caseload, both quit at the same time. Their patients had to be reassigned and because time was of the essence, they were simply distributed among four other counselors. This gave us an unplanned but very real opportunity to see if the counselor made a difference in patient outcomes. Remember that all of these patients had been stabilized on methadone. All had been in treatment for at least six months. They all had had a counselor, and now, we’re going to lose their old counselor and get, through what was basically random assignment, one of four new counselors. Well, it turned out that the counselors that they got really made a significant difference. Patients did reliably worse when they got changed to one particular counselor. Others assigned to a different counselor did reliably better. Turns out—surprise, surprise—not every counselor is a good counselor; and some counselors are really extraordinary.

This early finding led to a much more systematic effort. During the rapid expansion of methadone treatment in response to the AIDS epidemic, there was a call for “minimum methadone,” basically methadone alone, without any kind of counseling. This was and remains a well-intentioned effort to get this very potent medication to people who are using street opiates. So we asked, “Is a counselor really necessary?” We did a randomized controlled trial where patients got very minimal counseling—only an admission assessment—and then were brought up to a pretty conventional dose of methadone. A second group got the same methadone at the same dose, but they got regular, standardized counseling using the kind of model that the Johns Hopkins folks have used, developed by Maxine Stitzer. The third group got the same methadone, the same counseling as the second group, but they also got access to lots of social services: employment, psychiatric, medical care. The findings on any measure that you wanted to look at were just like a dose response. Patients who got methadone alone did show improvement, but it was modest; it was minor. Many of them had to be essentially rescued and then received more counseling. The patients who got exactly the same methadone dose plus counseling did much better, and the patients who got the combination of methadone, counseling plus additional social services did the best. In terms of cost-effectiveness, it was methadone plus good solid counseling that was best.

So that affirmed for me in both clinical ways and in cost-effective ways that counseling was essential. But the other thing that’s as important to say again is not everybody can be, or ought to be, a counselor. There are protocols to do counseling that can be combined with case management and information management. I’m afraid that not enough counselors are learning counseling as a profession. They’re simply being thrown into it and asked to “do group.” That’s not counseling.

Bill White: You’ve spent much of your career assessing the relative effectiveness of addiction treatment. What major conclusions have you drawn from the treatment effectiveness research?
Dr. McLellan: My idea was to look at the relative effectiveness of addiction treatment versus some other illnesses that I thought the public and certainly, I, felt were really effectively treated. I thought about conditions like hypertension, diabetes and asthma. I picked those because they were inarguably real medical conditions, and candidly, I really expected to see excellent results. So when my colleagues and I—Herb Kleber, Chuck O’Brien, David Lewis—did a literature review and looked at articles from the prior 10 years, we were frankly all amazed by it. There were so many similarities. The twin studies showed that the genetic heritability of opiate, alcohol, cocaine, and now marijuana dependence, was very similar to the heritability seen in twin studies of hypertension, diabetes or asthma. Management problems were almost identical. The biggest ones were lack of adherence. About 50 to 70 percent of patients who are in treatment for diabetes, asthma or hypertension don’t take their medications as prescribed and don’t follow through with recommended life changes suggested by their physicians. Correspondingly, the relapse rates are about the same: roughly 50 percent per year. Even the predictors of relapse were very similar: low socioeconomic conditions (i.e., poverty; poor family
supports; genetic heritability; and psychiatric symptoms) were all major predictors of relapse, not just in addiction, but in hypertension, diabetes and asthma. Subsequently, I’ve seen studies that have shown the same thing in response to dental management.

There are two conclusions I’ve drawn from all this. One, from a clinical perspective, I think addiction has much to be proud of—but also a long way to go. With far less support, far less organization, but far more use of individuals actively managing their disease (people in recovery), we’ve managed to have roughly the same levels of success and unfortunately, failure as other major illnesses. I think the next steps for our field are to incorporate some of the lessons learned from the management of other chronic illnesses. The second conclusion is that guys like me have been evaluating addiction treatment in the wrong way for a very long time.

Because addiction has been segregated, because its origins haven’t been understood, because addiction causes so many social problems, it’s been easy to think of addiction as a moral problem or a sin, and those who are addicted as simply criminals who need to be punished, taught a lesson, all that. God forbid you would have attractive, long-term treatments for that kind of a person. No, you want acute care, short and punitive. Better if they don’t like it. Better if they learn to get discipline and take their medicine.

Well, that is not the way you treat other chronic illnesses. It’s not the way you treat illnesses that don’t have a cure, and I don’t think we have a cure for addiction. We’ve had explicitly as our therapeutic goals to get people out of addiction treatment as soon as possible—to get them graduated. The rest of medicine realizes that if you don’t have a cure, the best thing you can possibly do is keep people in treatment. I’m not talking about residential care for the rest of their lives, but keeping them engaged in outpatient treatment for at least a year, perhaps two years, where relapses are anticipated, caught early, and intervened upon directly and therapeutically. That’s one of the most important lessons I have learned.  

The third and final thing I’ve learned is not only have we been evaluating it the wrong way, the government has been purchasing it the wrong way. The government is not purchasing the kind of sustained, outpatient, continuing, multifaceted care that the evidence shows has the best results. The government spends a lot of money on short-term detoxifications not followed by any other kind of care. That is money wasted.

Bill White: You recently collaborated with Deni Carise and Herb Kleber to address the question of whether the current infrastructure of addiction treatment could support the public’s demand for quality treatment. What were your conclusions that you drew from that study?
Dr. McLellan: I’m sorry to say that I have a very negative view about the current status of the United States addiction treatment infrastructure—particularly the infrastructure in the public treatment sector. I want to hasten to say I don’t hold the treatment professionals responsible for this state. I hold the government and the public responsible for this state.

We have brief interventions to intervene early in the development of substance-related problems that are very clinically effective and cost-effective. We’ve got medications for opiate, alcohol, nicotine, some indications for cocaine, not much yet for methamphetamine treatment, but we’ve got good medications. We have many evidence-based therapies that require sophisticated therapists, but that can have enduring benefits. These are not simply my opinions but facts based on two decades of very good research.

Well, the average treatment program in this country simply cannot implement most of those treatment ingredients. Most do not have a doctor, so medications are out. Most do not have integrated information systems, and there are government regulations that prohibit exchange of information between addiction treatment and the rest of healthcare, so case management and information management is very difficult. Most treatment programs don’t have a workforce that’s been adequately trained and clinically supervised.  Worse, because of contemporary funding constraints, I’m sorry to say I don’t think significant upgrading of training or clinical services is going to happen in these programs, again, in some significant part, because addiction treatment is segregated from the rest of healthcare financially, administratively and in terms of regulations and information.  
I do think it’s going to be a difficult transition, make no mistake, but I think ultimately the future of this field is to become part of the rest of healthcare. By the way, I’m not saying we should become integrated simply because it’s time for the rest of healthcare to do the addiction field a favor or even because it’s the right thing to do—although it is the right thing. No, I think integration of mental and substance use care into the rest of healthcare is one of the biggest favors we will ever do for mainstream healthcare in this country. Truly integrated healthcare will produce far better and far cheaper healthcare generally, and particularly for the many millions of ­people who currently have a range of untreated substance use disorders.

Bill White: One of the issues that has dominated many discussions in this past decade is the whole issue of the gap between clinical research and clinical practice as one dimension of this larger quality of treatment issue. What are your current views on the issues related to that gap between research and practice?
Dr. McLellan: Well, I think there’s no doubt about it. Elizabeth McGlynn, from RAND, published a study a few years back showing that in terms of integrating evidence-based practices—that is, clinical practices that research has shown to be effective—the treatment of alcoholism ranked among the lowest of all the medical treatments studied (she was not able to study drug abuse treatment). Of course, there is a research to practice gap in every healthcare disorder, but the gap is bigger and wider in the substance use field. Once again, I have to say I think it’s partly a function of segregation.

While much of the addiction treatment system is segregated from the rest of healthcare, most addiction researchers are very integrated into mainstream academic healthcare settings. So the medications, therapies and other interventions are generally developed in more academic,
full-service environments, often with better trained staffs and research infrastructures to back them up. That kind of infrastructure just isn’t available in the mainstream field, and thus many of the treatments that are studied and shown to be effective simply won’t fit in the “real world.” So, who do we blame for this—the researchers for working under very good conditions; or perhaps we should blame community treatment providers for working in much more difficult situations? Neither of these makes sense. We need to put infrastructure dollars into the kinds of treatment interventions that have the best results. Isn’t that what they do in the treatment of other illnesses?

Bill White: I was really struck by one of your recommendations to enhance the quality of addiction treatment resources. You recommended that addiction treatment be formally declared a distressed industry to bring additional resources to support workforce development. What do you think are some of the most important next steps for workforce development in the field?
Dr. McLellan: This is not an opinion; this is a fact. We don’t have near the number of trained professional counselors, social workers and psychologists working in the addiction field that we need right now. Second, a significant proportion of those people who are working are at or near the retirement age. Third, we don’t see new people standing in line to enter this field. That’s not all; the problem is going to be even worse because, as I’ve said repeatedly throughout this interview, the future is integration into the rest of healthcare. So, not only will we need to retain the professional skills and professional knowledge about substance use disorders that we’ve acquired over the last several decades and impart that to new people, we need to also upgrade our training. Counselors need to know much more about the genetics of addiction so they can explain to the families and the patients some of the origins of these illnesses. Case management skills are going to be necessary. Fundamental knowledge about medications as well as knowledge about, and ability to describe different kinds of treatments are all going to be important skills.

The labor department, who we’re now working with, is responsible for the training and development of workforces. In the past in this country, the declaration of an area of commerce that has particular importance for our society and has suffered workforce problems (e.g. electronics, alternative energy, farming, etc.) has been associated with an infusion of new money, new training programs, new credentialing and skill development programs all from the Department of Labor. Those kinds of interventions have been responsible for some of the dramatic developments in the electronics and farming industries in this country. I think they ought to be brought to bear in the behavioral health field, particularly addictions.

Bill White: I’ve acknowledged the article that you, David Lewis, Charles O’Brien and Herb Kleber published in the Journal of the American Medical
Association in 2000, on addiction as a chronic disease as a historical milestone in modern thinking about addiction treatment. What progress have we as a country and a professional field made since 2000 on our understanding of addiction as a chronic disorder requiring sustained recovery management?
Dr. McLellan: I don’t think we’re anywhere close to where we should be in terms of accepting addiction as a chronic illness, and—more important than anything else—acting on those expectations. In my current role, I am surprised virtually every day to meet people in highest levels of government agencies that work in the drug arena that have never imagined that addiction has public health implications. They think of it entirely as a criminal justice issue.

They say, “Well, if it’s an illness, it is one brought on by the individual” or “If it is an illness, it’s not a real illness.” They don’t understand that most illnesses in this country, particularly chronic illnesses, are brought on by the behaviors of those who ultimately contract the illness. Adult-onset diabetes, hypertension, asthma, tooth decay, lots of them are brought on by behaviors combined with genetics, and they produce really significant public health conditions that are unambiguously treated in healthcare  settings.

Perhaps worse, I hear lots of people who are working in the addictions field say the words “addiction is a chronic illness,” but they keep doing the same acute care kinds of treatments and addiction researchers keep evaluating the effects of addiction treatment with 12-month post-treatment outcomes. Insurance coverage for addiction treatment has finally begun to realize—as a result of parity legislation and now through the Healthcare Reform Act—that addiction ought to be managed the same way, in the same kind of an environment, with the same kind of clinical information exchange as other chronic illnesses.

Bill White: If we really did treat addiction as a chronic disorder, how would the current role of the addiction counselor change?
Dr. McLellan: Despite all the problems we have in our field and all the things we need to develop, we have one of the best fundamental models for the treatment of a chronic illness that you’re ever going to see. The addiction field has learned to integrate criminal justice interventions, where necessary, with therapeutic interventions, and that is a very important part of maintaining public health and public safety. Second, we have some of the most cost-effective and lasting recovery-oriented interventions that I know about in medicine. We found ways to get people who are recovering from addiction to work with others who are just entering or just thinking about entering recovery. I can’t think of a more cost-effective model for maintenance of treatment effects, and we are now seeing treatments for other chronic illnesses incorporating peer-led continuing support. So, all that is something we should be rightly quite proud of.

Recovery-oriented systems of care are starting to emerge in many places as they are now in Philadelphia and the state of Connecticut. As far as I’m concerned, they offer a very nice model for how you should treat other chronic illnesses in a cost-effective manner. With that said, I think people with behavioral health experience—counselors, social workers, family counselors, psychologists—who learn about addiction and learn about the methods to manage it through combinations of medications, family involvement, peer involvement, monitoring and social supports are going to be invaluable, not just to the treatment of addiction, but to the treatment of chronic illness generally.

Bill White: It is interesting to me that at this late stage of the field’s development, we are just getting around to defining recovery. You led the effort by the Betty Ford Institute to assemble a consensus panel to create a working definition of recovery. What would you say you’ve learned from that process?
Dr. McLellan: I think one of the more satisfying things I have been part of in my career was the effort by the Betty Ford Institute with a lot of other professionals—including yourself, Bill—to take on the task of defining recovery, not for the person who is in recovery, but for the great majority of the world who don’t know anything about it and often have misgivings and misunderstandings about the concept. It was challenging to develop a succinct way of presenting what is a very complicated concept. I took three lessons from this experience.  

First, there is no single way to get into recovery. That was a lesson I learned from you, Bill. The most popular and storied way of getting into recovery is through involvement in a 12 Step program. It remains one of the staples of our field, but it’s not the only way. Second, abstinence is necessary but not sufficient. People who simply don’t drink but continue behaviors and attitudes that are associated with an addiction lifestyle are not going to be abstinent for long as far as I’m concerned. Third, probably more important than anything else, is that recovery is not only achievable, it’s downright expectable.

There are, according to the Faces and Voices of Recovery, at least 20 million people today who consider themselves to be in active, stable recovery, and the public at large has no idea about that. Too many think that addiction is a lost cause. They think that there’s no real hope, and unfortunately, it’s because they don’t know that they are quite literally surrounded by people who are in recovery but don’t talk about it every day. This is one of the things that we want to make clear to the public: that recovery is not only possible, it’s expectable, and it should be the goal of every treatment episode. Having a solid, well supported recovery community is a tremendous resource for any community and any family and any individual.

Bill White: Were you surprised at the international interest that the Betty Ford Institute recovery definition consensus generated?
Dr. McLellan: Actually, no. Once you have a definition that people can agree on and can measure in sensible terms, the hardest work is done. I was quite certain that this process of defining recovery would be well worth the effort, and it has been. Countries all over the world are interested in adopting the definition or some variation of it. More important than adopting the definition—although I think that was the necessary first step—they’re developing strategies to bring recovery into much broader reality. That’s what’s been really gratifying about this work. It gives hope to people who really don’t think there is any hope. When they hear that 20 million people were in the same situation as they were in, that there are a lot of different ways to get into recovery, and that there are a lot of very willing people who can help them do it, that instills hope at the individual, family and community levels, and hope is the one thing this field desperately needs.

Bill White: The current call to transform addiction treatment into recovery-oriented systems of care seems clearly an outgrowth of much of your work. Do you see this current focus on long-term recovery as a sustainable movement as we go forward?
Dr. McLellan: I do. I think recovery is first understood from a clinical perspective but what will sustain it in the public perspective are the financial, public health and public safety benefits. Sustainable recovery is what makes treatment and initial care worth it. Because of this, it follows that we need systems that will sustain the recovery process. Good treatment without the additional personal and social investment in sustaining continuing recovery is like having a damn good junior high school education—very important but not near enough to make it in the world. Just like education, we need to make it clear to individuals, families and the public at large that short term, quick fixes or simply physiological stabilization is necessary but not nearly sufficient to manage substance addictions.

But I think you are right to emphasize not just recovery but also the recovery system of care. We have always had charismatic individuals who could bring individuals into recovery—wonderful, but not adequate. We need systems that can be created and implemented and managed at the community level that will make recovery an expectable outcome of becoming sober and beginning a new lifestyle. I think it’s going to be one of the most cost-effective kinds of infrastructure development that we will do in this country.

As we begin healthcare reform, addiction treatment will be quite dramatically effected. Addiction treatment will be part of the rest of medicine. A very realistic question is what will happen to the federal Block grant? My own view is the federal Block grant ought to remain, and that it ought to be more directed toward building and sustaining recovery-oriented systems of care. As individuals get interventions and initial primary care through the mainstream healthcare system of the future—and that care is reimbursed through Medicaid—they will hopefully get a kind of care that they’ve never had before, but they won’t be cured. What they’ll need is places they can go following that initial
care where they can get recovery support services: peer support services, ­parenting skills, drug free housing, help with job transition or job placement, family support services. That’s what I’m hoping the Block grant will be used for.

Bill White: Many people working in the addictions field draw upon experiential knowledge related to their own personal or family addiction recovery experiences. You have been quite public about how addiction recovery affected your family. How has this experiential knowledge influenced your work in the field?
Dr. McLellan: Anybody that has a particular kind of a disease in their family is more acutely aware of the research in that field and new interventions or proposed interventions or medications, and that’s been the case with me. I have worked in this field for 35 years, studied all parts of it. Not only that, through my whole professional life, I have been surrounded by some of the best professionals in the field. But with all that going for me—knowledge, contacts and benefits that most Americans do not have access to—I found myself almost completely lost when members of my family first got into trouble. Because I am pain­fully aware of just how devastating addiction can be when it strikes your family, I have been working with lots of my colleagues for the past several years to translate what we are learning from science into practical knowledge and skills and supports that can be used by parents, families and communities. The good news is that lots of researchers in this field have turned to this type of translational activity, and there are an increasing number of parent groups and community organizations that are coming forward to demand better and more practical interventions and skill development.

Bill White: On Aug. 10, 2009, you were sworn in as the Deputy Director of the White House Office of National Drug Control Policy. What enticed you to leave the Treatment Research Institute and assume this role?
Dr. McLellan: I had had a fairly public loss in my family as a direct result of addiction, and that, combined with a very persuasive telephone call from Vice President Biden, led me to believe that maybe I should leave what I really loved doing and the people that I loved working with to see if I could help this administration make a contribution to the field at a policy level. I have to say it’s been a forced fit to put me in a policy environment—and this will come as no surprise to those who have worked with me in the past. I am an impatient guy, I favor a “ready—fire—aim” approach and government is much more of a “ready—aim—aim—aim . . .” environment. If you think research or clinical work requires patience, oh baby, try national budget-making, priority setting and consensus building in the context of pitched ideological battles, suspicious federal agencies and intensely invested private interest groups!

I do know that our Director, Gil Kerlikowske, has really improved the morale and function of ONDCP, and we have unprecedented support and involvement from the Vice President’s office. Day to day, it’s like walking through jello, but I think we have a shot at really helping people in the long run. I miss terribly the puzzles and excitement of investigation and discovery with my friends at my old job.

Bill White: Could you talk about how you have tried to influence the future of addiction treatment through this role?
Dr. McLellan: First, it’s clear that addiction at a policy level now is predominantly considered a criminal justice issue and thus managed by Departments of State and Justice, and by various law enforcement branches within those agencies. While they’re all doing a very good job, I was surprised to find that many of my colleagues in these agencies are unaware of the new developments in prevention, intervention, treatment and recovery. So, what I have tried to do is enhance their knowledge and help them with some new tools to add to what they are already doing. Thanks to the leadership of Gil Kerlikowske, I think we have already formed some really good functional partnerships between what is called the “demand reduction” side of addiction policy and what is called the “supply reduction” part of addiction policy.

Second, I have tried to move addiction integration forward. Despite the pervasiveness of addiction problems, they seem to be hidden under rocks, under rugs and behind doors. And yet, substance use problems affect every part of mainstream society from education to business to healthcare, ­criminal justice and welfare. Part of my role here has been to help those in policy positions see that they will never get a handle on healthcare reform, prison reform, sentence reform, welfare reform or educational reform if they don’t address substance use issues. My sinister plot for insinuating this issue into mainstream policy is to show them that attention to substance use issues within their own areas will help them develop far better policies and programs—that attention to substance use issues will help them reach their own goals in a much better way. We can add value to the rest of mainstream society. Substance use and addiction as an issue needs to be part of mainstream society, not shoved off to the side.

Bill White: You recently announced that you will be leaving ONDCP at the end of September. What factors led to this decision?  
Dr. McLellan: It really boils down to two things and neither of them have anything to do with either my current position or with the staff or leadership of ONDCP. I am honestly very proud to have served with these people and I can say they are as committed and diligent a group as I have ever worked with.  

The first factor in my decision is that I think much of what I can do has been done with the passing of the Parity and the Healthcare Reform Acts.  Thanks to the work of many, many people working in and with government, we have an unprecedented future for the substance use prevention, early intervention and treatment fields. That legislation will bring our issue directly into the mainstream of healthcare and while it will not be smooth or easy, addicted people will have opportunities they never have had. While the legislation, regulation and money to bring this came from the hard work of many in the federal government, the actual translation of how these opportunities will emerge will not come from federal government—it will come from the innovation and dedication from public and private groups in our industry. I want to be part of the innovation and creativity that I think will generate from within and outside our field over the next decade. New solutions will be developed by people already in—but also people that are now outside our field. Those ideas and opportunities will be tried at the community level and those that show benefit will become incorporated while old ways and new ones that don’t work will be discarded. I think that is the way it should be and I would like to play some part in those efforts at the grass roots.   

The second factor is simply that government processes do not suit my personality. I do not like the partisanship and institutional defensiveness that I see in so many places in government. Both these factors combine to turn issues where there is an empirical answer into a political or populous decision. The answer to “What does 2 + 2 equal?” does not take a committee or a vote; and regardless of public support or outcry—it is simply the correct answer. Researchers spend their lives looking for correct answers and I like industries and environments that foster that process.

Bill White: There is considerable interest in what activities you will pursue after leaving ONDCP. What are your immediate post-ONDCP plans?
Dr. McLellan: I really do not know what I will do when I leave. I want to take some time and think about things. I will not make any decisions for at least two to three months while I do some relaxing, reflecting and soul searching. I do not want to retire—but I do want to regroup and reorient. Government has disappointed me, but it has not decreased my optimism. There has never been a better time to be in this field and I look forward to finding a useful opportunity to contribute for another 10 years or so.

Bill White: Are there any final messages you would want to convey to frontline addiction professionals across the United States?
Dr. McLellan: My final message to counselors and other addiction professionals would be that your work is critically important. Our field has turned a corner, and we are beginning to become integrated into mainstream society. And it’s your work that is making that possible.

William L. White, MA is a Senior Research Consultant at Chestnut Health Systems and author of Slaying the Dragon: The History of Addiction Treatment and Recovery in America.

Dr. McLellan served as Professor of Psychology in Psychiatry at the University of Pennsylvania, developed the Addiction Severity Index, authored more than 400 articles and chapters on addiction treatment, founded the Treatment Research Institute (TRI), and held the position of Editor in Chief of the Journal of Substance Abuse Treatment. He currently leads demand reduction efforts at the White House Office
of National Drug Control Policy (ONDCP).