A Follow-up Study of Alcoholism Treatment Units: exploring consolidation and change

A Follow-up Study of Alcoholism Treatment Units: exploring consolidation and change
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  British Journal of Addiction  (1988), 83, 57-65 A Follow up Study of Alcoholism Treatment Units:  exploring consolidation and change BETSY ETTORRE Research Associate, Department of  Politics  and Sociology, Birkbeck College, University ofLondon, Malet Street, London WCIE 7HX, United Kingdom. Summary The main aim of  this  paper is to provide feedback from a  recent  1984-85 follow-up study,  based  on an srcinalstudy of Alcoholism Treatment Units carried out from 1978-1982. On the whole, the paper  demonstrates  theusefulness of this feedback strategy and the value of this type of research. While the empirical information reported  in  this  paper speaks for  itself the  discussion  revolves around two main themes: (1)  changes  within thetreatment settings and (2) consolidation in the A  TUs  institutional response. Conclusions drawn from thisdiscussion confirm  the  future role ofATUs and  suggest possible  ways forward. Introduction In 1962, the establishment of a special treatmentsystem for alcoholics, the Alcoholism TreatmentUnits (ATUs) was recommended within the BritishNational Health Service.' In recent years. MaxGlatt, founder of the first ATU at Warlingham ParkHospital, alleged that this form of specializedtreatment had been scattered somewhat haphazardlythroughout the country's psychiatric hospitals.^''Linked with this allegation, a growing concern for a'broad based' type of service expressed by theAdvisory Committee on Alcoholism'' exposed theneed for an overall account of the shape of services,provided by this specialized treatment system.Given the above, a major study of all existingATUs was mounted in December 1978 by theAddiction Research Unit. Subsequently, the resultsof this study were reported in a series of publishedpapers focusing on treatment activities'; patientsettings;' staffing;'' links with the community' andthe rise of the concept of an ATU within a specifichistorical framework.' While the key theme for thisresearch was the notion of'special units for commonproblems',' the main aim of the study was toprovide an in-depth view of the range of ATUsexisting at that time.Overall, the findings suggested that ATUs pro-vided an institutional response which was bothdiversified and dynamic and the data pointedrepeatedly to the fact that as complex treatmentunits, ATUs operated very differently. There wasalso evidence of a possible process of drift withinthe total system where sharing of responsibilitybetween ATUs and general psychiatry (and indeedprimary health care) had not been adequatelythought through.This paper provides a summary of findings froman ATU follow-up study which has targeted issuesarising from the 'srcinal' ATU study. The idea tocarry out a follow-up study was born out of adistinct feeling that any future research endeavourwould investigate whether or not treatment trendscould be detected over time. The intrinsic value ofthis follow-up study is twofold: (1) it generates anew base of empirical information, comparable tothe srcinal data base and therefore, enables one toplot changes within the total treatment system and(2) it represents a methodological innovation (i.e.    58  Betsy Ettorre feedback in a research strategy), offering a genuineextrapolation of results from previous findings. Inrelation to ATUs as a whole, this has not beenattempted before.Given that the investment which the NHS makesin the treatment of alcoholism is extensive (i.e. themost recent figure is £17.4 million for 1981,estimated by McDonnell & Maynard ), this type of'jobbing research' should be viewed as an essentialexercise within effective health service planning. Itshould also demonstrate a valuable strategy usedwithin health service research. More significantly,this type of research and the reporting that followsshould help all concerned with ATUs' developmentto explore viable ways forward or simply to answer the,  as yet unanswered question: 'Where do we gofrom here?'. The guiding assumption of this currentwork is that the processes of feedback, systematicevaluation and evolution are seen to be beneficialwithin individual ATUs as well as within the systemas a whole. Research Design and Methods The follow-up study on ATUs began in May 1985and was completed in June 1986. During that timedata were collected from 29 ATUs, all included inthe srcinal ATU study. (One of the 30 ATUsincluded in the srcinal study had ceased function-ing in 1982 when the inpatient unit closed down.This unit was obviously not included in our follow-up study.)The information obtained in the follow-up studyincluded responses to a 7-page questionnaire dealingwith staffing, patients, unit activities, ATU linkswith community agencies and changes within ATUsover the previous 5 years. All follow-up questionswith the exception of two questions (one relating tochanges which had had an effect on the treatmentservice over the previous 5 years and one on thecommunity alcohol approach to treatment) wereidentical to questions asked in the srcinal study. Results Staff (a)  Psychiatrists.  Since the srcinal study, nochange was reported in the total number of consul-tant psychiatrists (n=34) who worked within theATU setting. While there was a slight increase inthe total number of consultant psychiatrists («= 11)who had a full-time work commitment to the NHSalcoholism service, a slight decrease in the totalnumber of sessions (both full-time and part-time)for all consultant psychiatrists was reported (seeTable 1). Table 1.  Consultant Psychiatrists: sessional commitments No. of sessions*1234567891011Total no. ConsultantsTotal no. UnitsTotal no, sessionsNo, of Consultants1979-803390530111834301941984-853280300011113429186* Part-time = l-10 sessions; full-time =   sessions. There were 68 psychiatrists below consultantrank. Of these 68 'other' psychiatrists, 29 workedfull-time, while the remaining 39 worked a total of125 sessions a week. Comparing these findings withthe findings from the srcinal study on totalsessional commitment of psychiatrists below consul-tant rank, the current findings represent an increaseof 33 sessions or the equivalent of three full-timepsychiatrists.(b)  Other  Staff.  Other ATU staff besides psychi-atrists included 297 nurses; 29 social workers; 22psychologists; 29 therapists; 19 secretaries/recep-tionists and 53 'other  staff,  such as domestics,clerks, etc. The most striking finding in this area ofreporting is the significant change in the number ofCommunity Psychiatric Nurses who increased from4 in 1979 to 46 in 1984, a rate of increase of 10,5(1050%) over the 5 years from 1980-85, Substan-tial changes were also reported in the numbers ofsocial workers (rate of increase =—27%); othertherapists (rate of increase =—60%), secretaries/receptionists (rate of increase =—55%) and 'other' staff,  such as orderlies, domestics, research workersor clerks (rate of increase =120%) (see Table 2). Total Patient Intake and New Patients As with the srcinal study, responses concerning  A Follow-up Study of Alcoholism Treatment Units  59 Table 2.  All ATU Staff (excluding psychiatrists) Staff categoryCommunity Psychiatric NursesOther NursesSocial WorkersPsychologistsOccupational Therapists'Other' Therapists*Secretaries/Receptionists'Other' StafftTotal no. StaffTotal no. UnitsNumber1979-804255402817234324434301984-85462512922209195344929% increase (rate of)1050-1-27-2117-60-551203*'Other Therapists=Art/music therapists; Psychotherapists or Physiotherapists,t'Other' Staff = Orderlies, Domestics, Research Workers or Clerks, Table  3.Patient Total Patient category Caseload of ATUs attendances were (Question: there to the'How many (patient category)Unit in (year)?')1979-80Number of patients*1984-85 %admissions/increaseInpatient admissionsDetoxification-patient admissionsOutpatient attendancesDay-patient attendancesTotal no, attendances/admissions3,4011,94125,77219,220 50 3344 5752 688 20,09625,098 52 4573438 2230 * The numbers refer to total case load, not to individuals treated. inpatient admissions, detoxification patient admis-sions, outpatient attendances and day-patient atten-dances mostly provided actual numbers, but occa-sionally only estimated numbers could be offered.For example, four units provided estimated ratherthan actual numbers of their inpatients, detoxifica-tion patients, outpatients and day-patients, while anadditional 3 units reported estimated rather thanactual numbers for their day-patients.Of the 52,457 admissions and attendances re-corded for ATUs in 1984, 4575 were inpatientadmissions; 2688 were detoxification admissions;20,096 were outpatient attendances and 25,098 wereday-patient attendances. These numbers refer tototal case load, not to individuals treated, (SeeTable 3 which also reports rate of increase for eachpatient setting.)For each patient setting, the largest numberreported by ATUs was for day-patients; the nextlargest was outpatients, followed by inpatients, thendetoxification patients. This represents a slightchange from the srcinal study when the ranking ofnumbers within each patient setting from the largestto the smallest was outpatients, day-patients; inpati-ents and detoxification patients. The drop inoutpatient attendances in 1984-85 could be due tothe fact that in some ATUs, patients traditionallyreferred to as 'outpatients' were now referred to as'day-patients'.Changes from the srcinal study were also re-ported for the ranking of the total number ofindividuals who had 'never been to the unit before'.The follow-up study showed that 59% of detoxifica-tion admissions; 58% of inpatient admissions; 30%of outpatient attendances and 7% of day-patientattendances included individuals 'new' to the units,while for the srcinal study the findings were 48%, 69%,  19% and 4% respectively. Thus, the majorityof both detoxification patients and inpatients werenew admissions, while (as in the srcinal study)  60  Betsy Ettorre outpatients and day-patients were usually repeatedattenders. All Types or Combination of Types of TreatmentSetting Provided by the Total Treatment System (AllATUs) in 1984 While as stated previously, ATUs provided fourtypes of treatment settings, not all treatmentsettings were provided in every ATU. Although allATUs reported that 'theoretically' they wouldprovide services for both inpatients and outpatientsand furthermore, all 29 ATUs with one exceptionresponded to the relevant questions regarding dif-ferent patient settings, the types of treatmentsettings varied among ATUs.Drawing on a compilation of data from responsesto the four survey questions on number of patientsin the different treatment settings, the compositionof treatment settings within the total treatmentsystem (all 29 ATUs) included 6 out of the 8categories found in the srcinal study. Given that inthe srcinal study it was stated that one mightassume a different composition would appear inprevious or subsequent years the findings are notsurprising.In addition, a comparison of the 8 categoriesfound in the srcinal study with the 6 categories inthe follow-up study reveals: (1) inpatient only (0ATUs in 1984; 2 in 1979); (2) inpatients andoutpatients (2 ATUs in 1984; 4 in 1979); (3)inpatients and day-patients (3 ATUs in 1984; 1 in1979); (4) outpatients and day-patients (3 ATUs in1984; 1 in 1979); (5) day-patients only (0 ATUs in1984; 2 in 1979); (6) inpatients, detoxificationpatients and outpatients (2 ATUs in 1984; 3 in1979); (7) inpatients, outpatients and day-patients(7 ATUs in 1984; 7 in 1979) and (8) all types (12 in1984; 10 in 1979).The majority of units in the follow-up study(n = 19) and the srcinal study (w= 17) appeared ineither of the last two categories: (7) inpatients,outpatients and day-patients or (8) all types ofpatients. Length of Inpatient Programme and Average Lengthof Patient Stay Responses regarding the length of the formalinpatient programme for ATUs shows that while themajority of units (w=19) reported the length of theformal programme to be 8 weeks or less, 1 unitreported 10 weeks and 3 units reported 12 weeks.An additional 2 units reported 'no formal length'. Inrelation to the srcinal survey, these responses showa slight decrease in the number of units reporting 9weeks or more as the length of the formal inpatientprogramme. The number of ATUs reporting 9weeks or more was 6 in 1979 and 4 in 1984.In the follow-up study no ATU reported theaverage length of stay for inpatients to be 10 weeksor more, while 5 ATUs reported this finding in thesrcinal study. Overall, the findings on the averagelength of inpatient stay was 5 weeks for those 23ATUs who responded to the survey question. (4ATUs responded 'not applicable' and 2 did notanswer the question). This finding represents achange in the average length of stay for inpatients, a —  28%  rate of increase over the past 5 years. (In1979, the average length of stay reported was 7weeks as compared to 5 weeks reported in thefollow-up study.) Pathways to Treatment:  referrals Unlike the srcinal study, ATUs responses toreferral questions tended to be high with 28 unitsproviding answers to the questions. The overallranking of referral agencies for inpatients was GPs;psychiatric hospitals; general hospitals; probationservices/prisons; social services; self-referrals;councils on alcoholism; Alcoholics Anonymous;hostels and the police. Reporting on 'other' patientreferrals showed the following ranking: GPs;psychiatric hospitals; probation services/prisons;general hospitals; social services; self-referrals;councils on alcoholism; hostels; Alcoholics Anony-mous and the police.Similar to the srcinal study, the findings showthat for all types of patients, GPs and psychiatrichospitals appear as the major pathways to treatmentfor ATUs, with smaller numbers of patients referredfrom general hospitals and the probation services/prisons. The Community Alcohol Team Approach WithinATUs One of the two questions asked in the follow-upstudy and not in the srcinal study was: 'Does yourUnit adopt a community alcohol team approach?'.Twenty-eight out of 29 ATUs provided an answerto this question and the answers included: 'wholly'(5 ATUs); 'in certain respects' (22 ATUs) and 'notat air (1 ATU).  A Follow-up Study of Alcoholism Treatment Units  61 Table  4.  Use  of  ontrolled  Drinking {Question:  'How often  is a  controlled drinking regimetried with patients?')ResponsesNever triedUsed with  1-24% Used with 25-74%Used with 75-100%No answerTotal  no.  UnitsFor inpatients16(16) 3  (7) 11  1)  8(9) 4  1) J 5  (5) 29  (30) Number  of  UnitsFor outpatients11(16)11(11)  1 2  (5) 15 (17) 2  (1) J 3  (7) 29  (30) For day-patients18  (9) 1  8) 1 2  (1) 5 (10)   1) J 6(11)29  (30) *The numbers  in  parenthesis represent findings from  the  srcinal study (1979-80), Procedures  and  Activities The srcinal study provided  a  general picture  of the types  and  variety  of  treatment procedures  and activities which were most used  by  ATUs  in 1979-80. Compared with findings from  the  srcinalstudy,  the two  most widely used procedures  for inpatients reported  in the  follow-up study were'group psychotherapy'  and  'counselling  by staff. In this area,  one  change  was  recorded when comparingthe follow-up study with  the  srcinal study: 'relaxa-tion sessions'  and  'physical exercises' ranked higherthan 'occupational therapy' which  was the  thirdmost popular procedure  for  inpatients  in the  srcinalstudy.For 'other' patients, specifically outpatients  and day-patients,  the  findings  on  procedures  and  activi-ties  in the  follow-up study mirrored  the  findings  in the srcinal study. 'Counselling  by staff,  'telephonesupport'  and  'group psychotherapy' ranked high  on the list of procedures  and  activities  for  both surveys. Controlled Drinking The findings  on the use of a  controlled drinkingregime  are set out in  Table  4.  Eight Units  had  triedcontrolled drinking with inpatients;  15  Units withoutpatients  and 5  with day-patients.  As can be  seenfrom Table  4, in the  srcinal study there  was  less  of a tendency  for a  controlled drinking regime  to be used with inpatients than with other patients  and most units used  a  controlled drinking regime withless than  25% of all  patients  or not at all. The follow-up study revealed: there  was,  unlike  the srcinal study, less  of a  tendency  for  controlleddrinking  to be  used with day-patients than withother patients  and  similar  to the  srcinal study,  the majority  of  units used  a  controlled drinking regimewith less than 25%  of all  patients  or not at all. Follow-up Options With  the  exception  of  'Medical checkup  at the  Unit'all follow-up options listed below were offered  by the majority  (n=14 or  more)  of  ATUs. Theseoptions listed from  the  highest  to the  lowest include:'follow-up interview with unit nurse'; 'follow-upinterview with  the  social worker'; 'home visit  by member  of staff;  'expatients' group meeting';'outpatient group'; 'join  a  day-patient group'  and 'follow-up interview with  a  psychologist'.These findings represent little change from find-ings reported  in the  srcinal  ATU  study.  In the follow-up study, more units  (M  =  18 offered  a 'follow-up interview with  a  community nurse' thanthe number  of  units («  =  15) offering  the  sameoption  in the  srcinal study. Also,  the  number  of units offering  the  option, 'medical checkup  at the unit' decreased from 19 units  in the  srcinal study  to 12 units  in the  current study. ATU Outpatient Clinics  and  Community Housing Sixteen ATUs between them  ran 37  outpatientclinics which were held outside  the ATU or the hospital where  the ATU was  located, while  1  unitwas  in the  'process  of  setting  up a  clinic'  and  anotherunit reported that 'domiciliary visits'  had  replaced'the need  for a  clinic'.In  the  srcinal study,  20  ATUs  ran  between them32 outpatient clinics, three being  the  highest numberrun  by any one  unit. These findings differed fromthe follow-up study  and  comparisons between bothstudies reveal: fewer ATUs  ran  more clinics  (16 ATUs  in  1984-85;  20  ATUs  in  1979-80); moreunits  ran  three  or  more clinics  in  1984-85 than  in 1970-80  (5  ATUs  as  compared  to 1 ATU) and 'domiciliary visits'  had  become  a  viable option,replacing  the  provision  of an  outpatient clinic  for one  ATU.
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