One of the major milestones in the modern evolution of addiction treatment has been the reconceptualization of addiction as a chronic disorder and attending calls to move beyond acute care models of intervention to models of sustained recovery management. This trend has been propelled in part by a growing body of posttreatment outcome studies and the evaluation of continuing care strategies that could potentially elevate long-term recovery outcomes. One of the central figures in this paradigm shift is James R. McKay, PhD, professor of psychology in psychiatry at the University of Pennsylvania School of Medicine. I recently had the opportunity to interview Dr. McKay about his research activities and the state of continuing care in the United States. Please join us in this engaging conversation.
Bill White: Dr. McKay, could you describe some of the influences and circumstances that led to your decision to specialize in addiction research?
Dr. McKay: I started playing the guitar in middle school, and by the end of high school that’s about all I wanted to do. I played in a couple of rock bands and studied classical guitar pretty seriously during that period. I also was drinking a lot and doing a fair amount of drugs and not putting any effort into high school studies. I did not go to college right out of high school, since I had lost all interest in academics and was pursuing a music career. By the time I was in my early twenties, the music thing wasn’t working out and my drug and alcohol use had gotten worse. After a couple of really scary experiences and some difficulties cutting back or stopping, I spent a month at Hazelden when I was twenty-three. In the year after that, I decided to get out of the music business and go to college. I took community college courses for a year to get my feet wet again—it had been a long time since I’d done anything academic. I ended up going to Loyola University in Chicago, which is where I lived and had grown up.
I went to Loyola thinking that I was going to continue in graduate school after college and become a clinical psychologist. I was very interested in addiction treatment and providing such treatment since it had been such a help to me. While at Loyola, I worked as a research assistant for Dan McAdams, who was a personality psychologist and who had been a student of David McClelland’s at Harvard. When it was clear I wanted to pursue a doctoral degree, Dan encouraged me to consider Harvard. I wanted to stay in Chicago, but he worked hard to push me out of the nest. I applied to a number of graduate programs, but ended up at Harvard working with David McClelland. The Harvard Psychology Department did not have strong addictions researchers at that time, but David McClelland had very wide ranging interests and supported my desire to focus on addiction-related studies. I did a clinical predoctoral internship at a methadone clinic in Cambridge, which was affiliated with Cambridge Hospital and also worked at the Brockton VA with Tim O’Farrell and Steve Maisto, psychologists who were doing addiction-related research. They got me involved in couples and family research and also early studies on relapse. Those were the early influences on my career. After completing my doctoral degree and a year of clinical training at McLean Hospital, I did a postdoc at Brown University, where Dick Longabaugh and Steve Maisto were big influences. Some of the early papers that I wrote made use of data that Dick had collected as part of his research or that Tim O’Farrell and Steve Maisto had collected in their work.
Bill White: You mentioned little specialization in addiction during your doctoral training at Harvard. Was that fairly typical of graduate psychology programs in the mid-1980s?
Dr. McKay: Yes, I think so. There were no courses on addiction. There were courses on depression, on schizophrenia, on other clinical disorders, on diagnosis, and on psychoanalytic and cognitive behavioral treatment at that time, but there was nothing on addiction specifically. Very little time was devoted to addiction in any of the other clinical courses that I took. My early addictions training came from the methadone clinic and then from a clinical internship I did at McLean Hospital where I was able to work at their addiction clinic and receive really good training and supervision. But addiction was not addressed in any significant way in my graduate program.
Bill White: What were the attitudes of psychologists toward their peers who chose to specialize in the treatment of addiction?
Dr. McKay: I think a lot of it depended on the professor that you were working with. McClelland was a very broad thinker and valued work on applied issues and problems, so he saw addiction treatment as a very important area. Other professors thought that research on things like schizophrenia, depression or bipolar illness was more legitimate than a focus on addiction. There was still a lot of confusion then as to what addiction actually was. Was it a brain disease? Was it a personal failing? Was it just a bunch of indulgent people who didn’t know how to say no to themselves? Seeing addiction as a personal failing made it somehow less important than disorders like schizophrenia, which was certainly not seen as the patient’s fault. It’s interesting that there was such a long-standing stigma or lack of interest in addiction from the academic community. I think this has changed over the past ten years or so, with a number of doctoral programs that now have excellent training in addiction treatment and research, and the surge in interest in neuroscience in clinical psychology programs.
Bill White: At the time you entered the field, there was a split between people in recovery who were working in the field and people who were entering the field with professional credentials. You entered with both recovery status and your doctoral training. I’m wondering if you felt any conflicts around that dual identity or pressure to disclose or not disclose your recovery status.
Dr. McKay: That’s a really good question and it’s one I feel I should have grappled with in a more open way. I felt very strongly early on that it was important to establish myself as a legitimate academic researcher, based on my journal articles and grant writing, rather than my own personal experiences of addiction and recovery. So, I did not disclose my recovery status. I wanted to be known for my academic credentials and expertise, and felt disclosing having been to Hazelden and that I was a person in recovery would prevent or detract from that recognition. Looking back now, I think I could have been more open about those experiences. Part of the issue was my struggle with a shifting of sense of self or identity. I had had this identity of being a guitarist, then the identity of being a person in recovery, and then the identity of being a graduate student and a budding academic researcher. It was hard at that point for me to integrate those things in a way that allowed them all contribute to my sense of who I was. It’s taken a lot of my career to figure out how to integrate the musician, the person in recovery, and the academic researcher—along with the other roles that one picks up along the way, such as a husband and parent.
State of Addiction Treatment during Early Career
Bill White: You entered the addiction treatment field in the mid-1980s. How would you characterize the state of addiction treatment at that time?
Dr. McKay: It was interesting because I worked at places where a lot of thought and effort were put into the design and execution of addiction treatment. It was not seen as the poor step-child of the organization as it was in so many places. At McLean Hospital, addiction treatment was seen as a legitimate area of clinical work and research, and at Brown there were people doing all this innovative clinical research in the addiction. Then I came to the University of Pennsylvania (Penn) where my original experiences were on the VA Addiction Recovery Unit, which was an incredibly progressive program at that time—offering veterans two years of outpatient care. So, in some ways, early in my career I saw the best of addiction treatment that was being offered.
In the mid-1990s, I got involved with many community-based treatment programs and quickly realized that not all treatment programs were as sophisticated or progressive as those to which I had first been exposed. Many community-based programs do not appear to have changed very much over the twenty-five years that I’ve been doing research; they’re still very AA- and abstinence- focused, virtually all services are provided via group counseling, and most of the newer, evidence-based treatments are not available. In a lot of ways, they’re run pretty much the way they were two decades ago. Certainly, there’s some strength to that. That model has helped a lot of people, but there typically isn’t much of a “Plan B” for people who don’t respond well to it. I think that’s one of the real limitations in the addiction treatment field. Too many programs offer one kind of treatment that works very well for a certain percentage of people, but if it doesn’t work for you, few if any alternative approaches are offered.
Inpatient versus Outpatient Treatment
Bill White: You were involved in some of the first studies comparing inpatient and residential addiction treatment with outpatient addiction treatment. What were the findings from those studies?
Dr. McKay: I was blessed by being able to use data that had been collected by Arthur Alterman and Tom McLellan here at Penn. They had focused in their papers on the main effect: residential versus outpatient. And what I was able to do was to factor in another variable that had been collected, which was whether the patients had been randomly assigned to these treatment conditions or had refused randomization and had either self-selected residential versus outpatient or had been placed in that level of care by a clinician. That allowed us to look at a methodological issue, which was, do you get the same results with randomized patients as you get with nonrandomized patients? This was a critical discussion given concerns that comparison of inpatient and outpatient outcomes may be biased by only including patients willing to be randomized to either setting. At that time, this question had not received a lot of attention in research studies. Random assignment of patients in outcome studies is the gold standard, but there are also patient and professional preferences that factor into level of care decisions. So it’s important to be able to look at outcomes under those two different conditions just to see how similar they are.
Bill White: And were the outcomes different across those two groups?
Dr. McKay: There may have been a few subtle differences but, by and large, we got the same outcomes whether or not subjects were randomized. The one limitation of this research—and it is true in almost all the studies of inpatient versus outpatient treatment—is that it is considered unethical to assign someone to outpatient treatment who clearly seems to need inpatient treatment. As a result, people with severe psychiatric problems or serious medical issues, for example, were screened out of these studies. So, the actual research question ended up being: In a population that can probably manage in outpatient treatment, does getting inpatient treatment confer any additional benefit? We couldn’t ultimately conclude that inpatient treatment offered such additional benefit under these circumstances. This is not surprising given that we were only randomly assigning people who probably could do okay in outpatient.
Continuing Care Studies
Bill White: One of your major areas of contribution has been on evaluating the effects of continuing care on addiction treatment outcomes. Was there a point in time when you saw yourself realizing this as a focus of your research?
Dr. McKay: I was interested in relapse, and by extension, this question of what do you do to reduce relapse in people who’ve been treated. The idea of continuing care seemed important. Back in 1992, Chuck O’Brien was putting in a competing continuation of a NIDA P50 center that he and Tom McClellan were directing. They were looking for additional studies to put into the center application and so Tom and Chuck sat down with me and asked if I would like to write a project for this center grant. I said, “Sure,” and in a five-minute discussion, we all decided that continuing care would be the focus of that project. It was as much the influence of Tom and Chuck as my own thinking about that area. But once I wrote that proposal and it was funded, it became increasingly clear to me just how important the issue of continuing care was to the whole field. For a junior person, that’s the sort of niche you’re really looking for. So I jumped into that and by 1998, it was quite clear that this was going to be a major focus of my career.
Bill White: You’ve had opportunities to write several research reviews answering the question, does participation in continuing care make a difference in terms of long-term recovery outcomes? For people who haven’t read those reviews, how would you summarize your answer to that question?
Dr. McKay: This question requires a complicated answer, but the simple answer is that for the average patient, there is moderately convincing evidence that continuing care can enhance recovery prospects above and beyond what patients would normally get in an episode of treatment and linkage to AA or other posttreatment referral resources. In the average patient, the effect of continuing care is not very big. There was a meta-analysis done just last year by some folks who did a really good job. My reviews have primarily been qualitative reviews, where I just add up the number of positive versus negative studies and try to make some overall conclusions. A meta-analysis actually turns it all into numbers and there are statistical procedures for analyzing the data. You can make stronger statements with this method, and meta-analysis of continuing care studies concluded that there was a small but significantly positive effect for continuing care versus no continuing care across all the different patients. That’s similar to the box score findings that I’ve done where I’ve found generally about half the studies seem to show a positive effect. I think what’s interesting is it is beginning to appear that there are certain patients for whom extended continuing care is really important and there are other patients who get along just fine without it. So, I think that that’s probably what’s accounting for the average to weak positive effects. There really are quite different subgroup effects of continuing care.
Bill White: And how would you describe the patient group that can most benefit from continuing care?
Dr. McKay: My sense is that the people who are going to benefit the most from extended continuing care are first of all patients who have a hard time getting abstinent at the beginning of treatment. If you’re in an intensive outpatient program and you’re continuing to use, we have pretty strong evidence from a recent study that you would benefit from extended continuing care, whereas the patients who quickly become abstinent and engaged in treatment may have less need of such care. The other patient groups that seem to benefit from extended continuing care are patients who have very poor social support and who remain enmeshed in alcohol and drug using family and social networks. Not surprisingly, they need something to counteract that influence. In our work, we’ve also found in a couple of studies that women benefit to a greater extent than men do. In our two big studies, there were pronounced effects in which women benefitted from continuing care to a much greater extent than men. Women in a standard community-based treatment program may be more vulnerable to relapse if they are not provided longer-term support.
Bill White: Some of your later research on continuing care has looked at telephone-based continuing care. What are some of the findings around the use of technology for continuing care?
Dr. McKay: I think that the use of the phone to deliver continuing care came from the fact that many patients just don’t want to keep coming back to the clinic week after week. They want and need support, but they don’t want to have to come to the clinic forever. Telephone contact is more convenient for people who are returning to work, who have childcare responsibilities, and who have trouble with transportation or travel distances. We found that you actually can deliver effective continuing care over the phone, although, interestingly, not everybody prefers it. We always have a certain number of patients who, when given the option, would rather come into the clinic and meet staff and others former patients face-to-face.
The thing we’re beginning to explore is the use of automated smartphone technology as a way of augmenting counselor-delivered continuing care. It can provide support 24/7 whereas access to continuing care contact with a counselor is limited to regular work hours. We’re working with David Gustafson’s group from University of Wisconsin on this. I think we’re on the cutting edge of new forms of continuing care that provide an interface of technology and traditional counseling. Our challenge will be how to maximize the strengths of each of these two modalities and how to combine them in a way that elevates long-term recovery outcomes.
On Recovery Management
Bill White: Under your influence and the influence of people like Tom McClellan and others you’ve referenced, the field has started to shift from acute care models of treatment to models of sustained recovery management and what you’ve described as concurrent recovery monitoring. How would you assess the progress of the field in making this transition?
Dr. McKay: I think there’s been progress. There has been excellent research on continuing care by a number of investigators, including Mike Dennis, Chris Scott, and Mark Godley from Chestnut Health, and Connie Weisner and colleagues out at Kaiser and UCSF. The idea of continuing care and more recovery-based approaches are certainly more popular and talked about a lot more now. Even some of the old-line residential programs like Caron, Hazelden, and Betty Ford have initiated extended continuing care programs that include things like telephone-based recovery checkups. The need for sustained recovery management is widely discussed and an increasingly accepted model of care.
The struggle is that it’s a lot easier to talk about it and lay it out on paper than it is to actually do it. Implementing effective continuing care is difficult on a number of different levels. There are all the logistic and payment-related issues. There’s the question of coordinating care: Who is responsible for continuing care when multiple organizations have been involved in the patient’s continuum of care? Even when you have all the bells and whistles and you provide a seamless continuum, patients still disappear on you. They lose motivation and they drop out. How to retain people, even when you have a great continuum, becomes a really tricky question. That may be where some of the new technologies can help. We’re always dealing with the fact that it is a challenge to keep people engaged—both when they’re getting on with their lives and when they are really struggling.
Bill White: Are we as a research community at a point where we can tell the typical program one or two things that they can do to enhance recovery outcomes of their patients?
Dr. McKay: I talk to programs about paying close attention to how the patient is doing in the first few weeks of treatment. Are they making progress toward the goals of treatment? Have they stopped using? Do they seem to have good social support and motivation for change? For patients who are not making good progress, I would be particularly focused on trying to arrange for extended recovery support for them, whether it’s continuing care or a longer stay in treatment. Such patients may need closer linkage to community supports such as assertive linkage to AA and assistance getting a sponsor. Plans for continuing care for these patients must begin almost immediately rather than waiting until the end of treatment to figure out what they need next. I think what we’re learning is that initial progress in treatment is a really good predictor of how people are going to do later on and who’s going to need the most additional long-term support.
Bill White: What kinds of real world obstacles are you encountering in delivering such long-term support?
Dr. McKay: I can give you an example. We’re running into a problem with a study where we want to use program counselors to provide extended telephone continuing care to patients after primary treatment. The idea is that by using the same counselors, we will enhance continuity of care and support and prevent these patients from deteriorating to the point that they need readmission to acute care services. The problem we’ve run into is about state regulations that require a patient be discharged once they stop coming to the clinic. After thirty days of no clinic contact, you have to discharge the patient. So, when the counselor is calling the individual two months later, he or she is no longer a patient at the clinic. As a result, the counselor is not protected under the clinic’s malpractice insurance for work with this individual. Understandably, the counselors don’t want to provide continuing care if they have no insurance coverage for this professional activity. It’s a double bind. You want to provide extended counseling and support to a discharged patient, but you don’t have insurance coverage once the patient has been discharged from treatment. Philadelphia is a pretty progressive city and they’re trying to do something about this, but the state laws and regulations now stand as obstacles to moving beyond acute care models toward sustained recovery support.
Bill White: As you look back over your career to date, what do you personally feel best about?
Dr. McKay: There are a couple of things. I feel very fortunate to have had the opportunity to collaborate and work with people in the field who are, by and large, very compassionate, dedicated, and inspired clinical researchers. I think the field itself is a wonderful field with a lot of supportive people whose work is very good. I feel good that a lot of my work has been done in real world clinics. I’ve been pretty committed to studying how to improve treatment for patients in clinics. Given my own early history of alcohol and drug problems, I feel like I’ve been able to give back some of the help I got as a young man. Frankly, I am grateful for just having survived my late teens and early twenties, and to have gone on to do something productive and personally meaningful. I have had the opportunity to work on interesting applied problems that affect a lot of people. I’ve been fortunate to be in an area where doing good work matters and has the potential to affect individuals, families, and communities.
Bill White: Is there any guidance you would offer others who today might be thinking of exploring a career in addiction research or addiction treatment?
Dr. McKay: I hate to be negative about this, but the truth is that it’s gotten much harder to get money to do addiction-related research. The kind of career that I’ve had where I’ve been grant-funded for my entire career on soft money in a medical school environment has been great. It’s afforded me tremendous freedom and flexibility, but it’s harder and harder to get money to have that kind of career. So, I think that people considering work in this area should be thinking about combining perhaps a teaching position with some research or a position in the VA or something where there is some hard money support that provides security to sustain this work for the longer haul.
The other thing is that for better or for worse, the addiction research field is becoming increasingly focused on biomedical research. The hope is that if neurobiological research can reveal what makes people vulnerable to addiction at a biochemical level, then there may be medications or other medical interventions that can fix that. Potential researchers will have more opportunities if they’re open to doing that kind of neuroscience-related work. People who, like me, are interested primarily in behavioral interventions will find research funding more difficult to garner and sustain. I think people earlier in their careers need to weigh their choices in light of the trends and what’s going to be possible. I think there will actually be quite expanded opportunities in the clinical practice of addiction medicine and addiction counseling as a result of such things as the Affordable Care Act, parity, and so forth. I think this could be an exciting time clinically as new models of care are rolled out with greater integration with primary care. I think there are going to be a lot of opportunities.
Bill White: Dr. McKay, thank you for taking this time to reflect on your work in addiction research.
Dr. McKay: It’s been a pleasure, Bill.
Acknowledgements: Support for this interview series is provided by the Great Lakes Addiction Technology Transfer Center (ATTC) through a cooperative agreement from the Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT). The opinions expressed herein are the view of the authors and do not reflect the official position of the Department of Health and Human Services (DHHS), SAMHSA, or CSAT.