Commentary
Robin Room
Alcohol and drug treatment
systems: What is meant, and what
determines their development
B
ergmark (2010) proposes that three concepts of “treatment
system” are in common use. One is a loose categorical
descriptive term, referring to an ad-hoc collection of treatment
services sharing some characteristics, often including geography and mode of financing. Terms such as “alcohol and drug
treatment system” or “substance use service system” are indeed commonly used with such a descriptive meaning, with
the phrase including also that the services are in some way intended to ameliorate or prevent alcohol- or drug-related problems for those served. This usage drains most of the meaning
out of the term ”system”; as Bergmark notes, the usage does
not necessarily claim that the services are components of “a
discrete entity composed of interrelated parts”.
Two other usages delineated by Bergmark are programmatic: the system is defined in terms of preferences or a program
for changing it. One of these meanings is in terms of what
Bergmark describes as an “extensive system approach”. The
emphasis is on the need to link up treatment services specifically oriented to alcohol and drug problems to a wider range
of mental and physical health, welfare and correctional ser­
vices, whether by combining services, referral, cross-training,
or other means. Glaser’s “core-shell model” was a version of
this “extensive system approach”, in that the “shell” was to
include a wide repertory of services looking to needs beyond
the usual scope of an alcohol or drug treatment service.
Included in the ideal of “joined-up services” is a critique
which contrasts the relative specificity of the services provided
by treatment agencies with the multiple life and health prob-
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Alcohol and drug treatment systems:
What is meant, and what determines their development
lems of many in the clientele. However, pro-
Bergmark quotes from work in this tradi-
motion of the ideal often seems to be driven
tion a long list of desiderata for a treatment
by professional turf claims rather than by
system, beginning with “rationality”, and
evidence of better outcomes; the evidence
notes that it is more a wish list than a prac-
base that joined-up services necessarily
tical program. In his conclusion, Holder
result in improved outcomes is quite thin
comes close to agreeing with this in ad-
(e.g., Krahn et al. 2006; Butler et al. 2008).
dressing the question of why existing or-
Also, putting alcohol and drug services into
ganizations or agencies do not follow his
a common system with a particular set of
prescription. Governments do not require
other services – for instance mental health
accountability of treatment results, and re-
services – may tend to institutionalize ne-
sources are limited, he says; “As a result,
glect of the other dimensions of health and
without both accountability and support
social problems often afflicting the clientele
of routine evaluation, the viability of the
of alcohol and drug services.
proposed systems approach is limited”.
The third usage, listed first in Berg-
Thus there seems to be some justification
mark’s abstract, is in line (as he notes)
for Bergmark’s characterization of the tra-
with general systems theory in focusing on
dition of thinking and usage as a “dream
the interrelations between the units or ele-
of rationality”.
ments which compose the system. Hold-
Bergmark goes on to propose a fourth
er’s (2010) paper is an extended essay in
perspective, switching from thinking in
this tradition of the meaning of treatment
terms of a treatment “system” to a treat-
systems. Holder’s essay exemplifies char-
ment “market”. He notes that the advent
acteristics of this tradition described by
of government contracting-out of services
Bergmark: a strong orientation to rational-
(as part of what is termed in Europe “New
ity and evidence as the basis for redesign-
Public Management”, NPM) has brought a
ing the system’s units and relationships.
new element of competition into alcohol
Holder lays out a series of steps to be un-
and drug treatment services. Control is
dertaken to reform any existing collection
also mentioned as an element in NPM –
of alcohol and drug treatment services,
but it seems to me there was also control
with an emphasis on outcomes, interven-
(often more directly exercised) in the older
ing variables, and a logic model for system
arrangement of hierarchies of civil-servant
design. While firmly located in Bergmark’s
treatment personnel.
third tradition of meaning, Holder’s vision
In the U.S., the shift to government con-
includes an element of the second tradi-
tracting-out of alcohol and drug treatment
tion, in that he subsumes treatment servic-
services, either through a master contract or
es into a wider frame of a “total system of
on a case by case fee-for-service basis, oc-
community response”. For Holder, the evi-
curred already by the early 1980s (Weisner
dence base to be considered is what hap-
& Room 1984). In the U.S., the motivations
pens to rates of alcohol and drug problems
for the shift seem to have been more di-
at the “population level”, not just in terms
verse than in the European NPM ideology,
of improved treatment outcomes among
arising in part from 1970s idealism about
those who come to treatment.
putting governments in “partnership” with
576
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Alcohol and drug treatment systems:
What is meant, and what determines their development
non-profit grassroots agencies. However it
or welfare insurance, or whether it be paid
arises, there is no question that a contract-
from private family or employer resources.
ing system brings competition into the
While financing is a crucial determinant
service system, which pulls against efforts
of any treatment system, it is not the sole
to “join up” and increase linkages between
determinant. Ideology also plays an im-
agencies. But the extent and effect of com-
portant role – how alcohol and drug prob-
petition should not be overemphasized: the
lems are conceptualised, and what are
agencies under contract understandably
seen as appropriate responses to alcohol
put considerable energy into efforts to con-
and drug use and problems. A recurrent
trol their funding environment, and in the
distinction here is whether it is the drug or
small worlds of local service-system poli-
alcohol use itself which is seen as the ob-
tics the result is often considerable stability
ject of treatment, or whether it is rather the
in the list of contract agencies, even if their
preventing or mitigating of problems from
tasks may mutate over time.
use. With respect to illicit drugs, there has
I agree with Bergmark’s impulse to de-
thus been an ideological divide between
velop a more adequate descriptive (rather
“harm reduction” approaches and treat-
than prescriptive) analysis of alcohol and
ments focusing on eliminating drug use;
drug treatment systems, and I also agree
for alcohol, there has been an analogous
that the market aspect of the system is an
divide between “controlled drinking” ap-
important attribute of many systems today
proaches and Twelve-Step approaches
– an aspect which has substantial influ-
focused on abstinence. A partly-related
ence on how treatment services individu-
ideological divide has arisen from the
ally and collectively function and develop.
strong roles of Alcoholics Anonymous and
But NPM contracting still does not guide
other mutual-help movements in social re-
the operation of every piece of the system
sponses to alcohol and drug problems in
everywhere. Alcohol and drug treatment
the last 70 years, which have meant that
does not operate only by competitive con-
experience-based approaches to treatment
tracting out to nongovernmental agencies
have been in ideological and often practi-
– among numerous counterexamples are
cal competition with professionalized ap-
US Veterans Administration alcohol and
proaches to treatment (e.g., Stenius 1991).
drug treatment, treatment in most prison
Cross-cultural comparisons of alcohol and
services, and Medicare reimbursement
drug treatment systems underline that
to Australian primary care doctors for
ideological differences also extend in a
methadone maintenance. A more general
number of other directions, most notably
conceptualization of this dimension of
in the variation in governing images of al-
determinants of the treatment system is in
cohol and drug problems between socie-
terms of financing, whether directly from a
ties and across time (Room 2001).
government through competitive contract-
A related but distinct set of determi-
ing, employment or reimbursement of pro-
nants is the professions and institutions
fessionals, or “voucher” systems earmark-
with custody of alcohol and drug prob-
ing resources for specific clients, whether
lems. Whether the governing image of the
it be indirectly through mandated health
problems is in terms of mental disorder,
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Alcohol and drug treatment systems:
What is meant, and what determines their development
physical disease, a workforce, housing or
lar agency offers them means that, from
family problem, or a crime tends to have
the point of view of the clients’ own pref-
strong influence on which professionals
erences, they benefit from a greater vari-
and social institutions will be given prime
ety of choices between agencies, and may
responsibility. But older governing images
lose options if the agencies become more
typically do not disappear, and institu-
“joined up” and rationalized into a system
tional and jurisdictional changes may lag
sharing client information between agen-
well behind ideological changes.
cies. The clients of services on Skid Row
Lastly, an important set of determinants
in San Francisco (Wiseman 1970), for in-
of alcohol and drug treatment systems is
stance, had more choices with a system
the social standing and power position of
that was fragmented than they would have
the clients. Bergmark discusses the diver-
had with an integrated system. The social
gence from the classic concept of the mar-
position of the clients thus affects not only
ket involved in the fact that the purchaser
the provision and funding of services but
of the treatment services is usually not the
also the extent to which the integration of
client, so that the “needs” of the client
services would be viewed by the clients
are often defined by someone else rather
positively or negatively.
than by client preference. But the split be-
In my view, financing modes and prac-
tween purchaser and client exists also for
tices, ideological frames, patterns of pro-
any publicly-funded health service, and
fessional and institutional jurisdiction,
while the client typically has considerable
and the clients’ social power situation all
say concerning his/her “needs” in such a
play important roles in the construction,
system, the purchaser there also has a say.
development and functioning of alcohol
What is different about alcohol and drug
and drug treatment systems. Each of these
treatment services is that the clients are
aspects is interconnected; financing, for in-
very often marginalized and stigmatised;
stance, influences ideology, and vice-versa
indeed, there is usually a stigma around
(Weisner & Room 1984). Yet variables in
the very fact of coming to alcohol or drug
each domain also play an independent role
treatment (Room 2005). Often those com-
in how systems are defined and change. At-
ing in the service door are under consider-
tention to each domain is thus needed in
able coercion, whether from courts or wel-
descriptive and comparative analyses of al-
fare workers or informally from family and
cohol and drug treatment systems as they
friends (Storbjörk & Room 2008). In these
actually exist and develop.
circumstances, the clients are not in a
good bargaining position concerning what
services are offered to or pressed on them.
The greater the degree of coercion in the
system, the more it can be organized so the
benefit to the clients is secondary to the
convenience of those staffing the system.
That the clients’ preferences may have
little influence on what services a particu578
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Robin Room, professor
Centre for Social Research on Alcohol & Drugs
Stockholm University, Sweden;
School of Population Health
University of Melbourne;
AER Centre for Alcohol Policy Research
Turning Point Alcohol & Drug Centre
Fitzroy, Vic. Australia
E-mail: [email protected]
Alcohol and drug treatment systems:
What is meant, and what determines their development
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