Measuring Social Model in California: How Much Has Changed?
Kaskutas, Lee Ann, Keller, John W., Witbrodt, Jane, Contemporary Drug Problems
Publicly funded substance abuse treatment programs in California have traditionally followed a philosophy known as the "social model" approach (Borkman et al., 1998; Room et al., 1998), in which clients are immersed in the sober social network, culture, and values of the recovering community of program peers, program alumnae, and Alcoholics Anonymous and Narcotics Anonymous members (Barrows, 1998). Social model programs are self consciously oriented, not medically or psychologically oriented (Borkman, 1990; Schonlau, 1990), although the model was noted by the Institute of Medicine as an exemplar of the socio-cultural approach to treatment (Institute of Medicine, 1990). The social model approach referred to here is primarily a California phenomenon, where providers sustained an active social model movement (Shaw and Borkman, 1990) that shaped the face of public treatment services (influencing how counties received and allocated treatment dollars, and institutionalizing a peer-- certification process conducted by fellow social model advocates (Borkman et al., 1996; Borkman et al., 1998; California Association of Alcoholic Recovery Homes, 1992; Institute of Medicine, 1990). However, as the substance abuse field has matured, like others (Di Maggio, 1991; Di Maggio and Powell, 1983) it too has become increasingly professionalized (Schmidt and Weisner, 1993), challenging the wisdom of the social model valuation of experiential knowledge in recovery (Borkman, 1990) and leading to increasing pressure for staff licensing and clinically oriented program certification requirements for providers desiring reimbursement of client fees (Crawford, 1998; Lewis, 1990a; Lewis, 1990b; Reynolds and Ryan, 1990; Wright, 1995). Related to this, the cost containment efforts of managed care have led to the ascendance of case management systems within the public sector, wherein licensed clinicians are required to develop and monitor the execution of patient treatment plans (Bois and Graham, 1993). While staff at other types of programs also have been hit by these increasing demands for documentation and monitoring of client progress for accountability purposes (Kaskutas et al., 1998c), this strikes at the heart of the social model philosophy, where clients are expected (and entrusted) to take charge of (and responsibility for) their own recovery (Borkman, 1998; Schonlau, 1990). The increasing numbers of clients who are mandated to treatment from the prison and court systems has further compromised this basic social model tenet of client-initiated, client-driven recovery (California Association of Alcoholic Recovery Homes, 1974; California Association of Alcoholic Recovery Homes, 1992; California Office of Alcohol Program Management, 1974; Shaw, 1990).
Other, broad-ranging factors may also contribute to a compromise in the fidelity of an original model of care: these include changing social constructions of a problem (e.g., from a disease to a moral failing); changing philosophies within the larger professional field (e.g., from treatment to prevention); changing funding guidelines (e.g., implementing prospective payment and diagnosis-related groups or DRGs; shortened stays; more paperwork for accountability (and case management systems being required); changing characteristics of clients (e.g., from alcoholics to alcoholics and drug addicts, or from voluntary to mandated); changing characteristics of service institutions (particularly the shift from categorically segregated, addiction-focused agencies to agencies merged under large behavioral health or human service umbrellas); changing characteristics of service workers under the influence of credentialing/professionalization (i.e., shifting away from recovery as a priority for staff); and the movement through various developmental stages in the life of a professional field (particularly the shift from its grass roots origins to its evolution into formal organizations). Since the 19$0s a number of these factors, especially the combination of professionalization under the managed care rubric, have affected the ways that social model programs have been allowed to function, often with detrimental results. …