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The Art of the Possible
Watching “Mrs. D,” an articulate patient who spoke at a recent Psychiatry grand rounds, is like looking at the surface of the Amazon; there’s no inkling of what lies beneath. Then it’s made clear: a violent, alcoholic father, a chaotic childhood that included sexual abuse, social anxiety so intense that she fainted addressing a group in the school auditorium and, as an adult, left a good job rather than accept an award in public. Alcohol and cocaine dulled all that but was fueled by prostitution. Then came heroin use. At age 50, Mrs. D’s life was a drug-dependent haze, punctuated by failures in rehab. Jailed for doing drugs, then homeless and depressed, Mrs. D knew she’d never get well. Even her cocaine overdose didn’t work.
Yet in leading the rounds, psychologist Robert Brooner, who directs Hopkins Bayview’s Addiction Treatment Services (ATS), described a program that’s made him, unlike many in the addictions field, optimistic for the Mrs. Ds of the world. It’s also opened him to criticism.
Brooner treats the chronically drug dependent, a cure-defying subset of patients with multiple addictions. He sees them as “terribly demoralized” because, time and again, year after year, they stop, then return to substance use. “They come to believe there’s no sense in quitting because they always go back,” he says. “But the real problem isn’t that stopping is impossible. They frequently do that. It’s that they stop trying to stop.” So the approach he and ATS colleagues use not only fosters a halt in drug use; it aims to extend that drug-free interval long enough to convince patients of the possible.
The clinic employs pharmacotherapies like methadone, counseling and behavioral reinforcement—nothing, Brooner says, you couldn’t find at other facilities. Yet with the Hopkins program, more patients stop drug use and gain employment—two measures of success—than at many other places. Why? In part, Brooner thinks, it’s because most places focus on only one or two of the techniques—methadone, for instance, and some counseling. The ATS strategy, however, interweaves the three.
Most important, it sidesteps what Brooner calls a crisis in therapy, namely, the huge mismatch between what clinics believe they deliver to patients and what’s actually received. “You may think higher methadone doses therapeutic, but writing a prescription isn’t curative if the patient doesn’t receive it.” So Brooner has made improving patient adherence a priority, powering it with the basic principles of behavioral reinforcement that colleagues Maxine Stitzer, George Bigelow and others have spent decades fine-tuning for addictions use.
Once they’re adjusted to methadone, patients enter ATS’s four-step program at a level that requires a weekly counseling session and urine tests. Good attendance moves them to steps with less-frequent counseling and easier access to methadone. Dodging brings steps with progressively more counseling. And, though the door back into the program is always open, continuing poor attendance results in discharge.
Critics believe Brooner’s approach requires too much of patients. He disagrees: “The field often expects too little.” Moreover, the program—unique in the way both steps and reinforcement work together to match the intensity of therapy to a patient’s needs—works. Sixty percent of those in the program test substance-free and 93 percent are employed.
As for Mrs. D, she’s been “clean” 18 months, thanks to a variation of the step program that reinforces success with vouchers for dental care, rent money, clothes and the like while it rewards employment. “I’d have been a fool,” she says, “not to take advantage of this.”
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