Comparing addiction treatment success rates across different care providers and approaches might seem like an apples-to-apples assessment, but it's not. For the most part, the addiction treatment field lacks consistently reported—and, in some cases, scientifically valid—ways of measuring the impact of treatment services. Psychiatrist Marvin D. Seppala, MD, and addiction researcher Audrey Klein, PhD, join host William C. Moyers armed with key questions consumers should ask treatment providers about their results: How do they define success? (Length of sobriety? Quality of life indicators?) What percentage of their patients get better? How do they conduct patient follow-up? (By phone? How frequently? For how long post-treatment?)
0:00:16 William Moyers
Greetings and welcome to the Hazelden Betty Ford Foundation Let's Talk series of Podcasts. I'm your host, William Moyers, and I've worked for Hazelden since 1996. But before that, I was treated at Hazelden and so that makes me a person in long-term recovery from addiction to alcohol and other drugs. Indeed, I am an alum of the organization. Thanks for joining us and for listening in today on this series of conversations with my colleagues about the important issues at Hazelden Betty Ford. That includes prevention, research, treatment and recovery support. Today we're talking about outcomes. And I have two distinguished guests on this very needy and weighty and controversial subject of what makes a good outcome.
0:01:04 William Moyers
Dr. Audrey Klein is the Executive Director of the Butler Center for Research at Hazelden Betty Ford. Dr. Klein joined Hazelden in 2007. She has a PhD in Experimental Psychology and her Masters in Cognitive Psychology. And if that's not enough she also had an MBA. And so Dr. Klein before we get going here I have to ask you with all things Psychology, why the MBA?
0:01:31 Dr. Klein
Well that is an interesting question, William. So a couple of things briefly. So the first is that I am a scientist. I am a scientist at my core, in my heart, in my spirit and by profession. But as I was working within the addiction field and even in my role at Hazelden Betty Ford, I realized that I didn't have a lot of business acumen and business knowledge. At the same time, I have really cultivated and grown this passion and interest in continuously trying to find ways to provide treatment and do better and—and different and come up with innovative approaches both within Hazelden Betty Ford as well as working with other providers of treatment to try to design newer, better, different solutions to help people in recovery. In order to do that and decide which services and products and for which folks and how do we get them in their hands and out to the marketplace, I really needed a—a bit of a business background. Which I'm—I'm pretty safe to say I got. So.
0:02:42 William Moyers
Well thank you. Your title is Executive Director of the Butler Center for Research. Most people who know our organization and know our history know that in 1949, we were founded in Minnesota—
0:02:52 Dr. Klein
0:02:53 William Moyers
As a place for people to find help for their alcoholism. The research piece most people don’t know about. Why is research important?
0:03:01 Dr. Klein
Yeah, people say it's so weird that a treatment center has a established research area. And the reason for that is thanks to the vision of two of our founding fathers, Pat Butler and Dan Anderson were two fantastic men who helped to get Hazelden Betty Ford started decades ago. They felt very strongly that if an organization is trying to help patients and trying to get them better and providing care, that organization is absolutely obligated to study the impact of what they're doing. So we—it is our responsibility as an organization to be measuring very carefully and very thoroughly how patients do while they're in our care as well as after they leave treatment with us. So that—that ongoing measurement—out—measuring patient outcomes continuously learning about how patients are doing when they come and see us if absolutely a part of our care model and how we treat patients. The Butler Center for Research has been collecting data on patient outcomes and sharing that data in terms of reports and publications for many, many years. And that’s a primary thing that we do still for the organization.
0:04:25 William Moyers
Also to talk to us about outcomes today is Dr. Marvin Seppala our chief medical officer of the Hazelden Betty Ford Foundation. Dr. Seppala is the top doc in our organization. He's innovative, he's passionate and he certainly has the knowledge. He joined the organization in 2002. But before that Dr. Seppala, you had a personal connection to the organization that you've always been open about sharing. And if you wouldn't mind sharing that with us today.
0:04:54 Dr. Seppala
Sure. I attended treatment at Hazelden in Center City, Minnesota in 1974 after dropping out of high school as a senior. And it didn't take—I didn't get sober at that point, they suggested—there was no follow-up in the Rochester area of any kind for someone my age. And so they told me to go to AA and I lived 11 miles south of Rochester in Stewartville and I thought it seemed like a long way to go for something I'd never heard of. And didn't really know that I'd need. And so I relapsed almost immediately. And as we're talking about outcomes, I was a failure and a bad outcome initially. And yet within about a year and a half I finally made my way to Twelve Step meetings and got sober and have been sober for 43 years now. And—and so in a way, there's a long-term good outcome but my—
0:05:47 William Moyers
0:05:48 Dr. Seppala
And—and it started at Hazelden. It really did. When I finally walked into Twelve Step meetings that—that's why I did 'cause they told me I should that I needed it, that I really had this disease and needed to get into recovery.
0:06:02 William Moyers
Well that whole issue of outcomes is—is controversial and kind of hazy at times because I don't think our field has really done a very good job of ever developing a set of outcomes that everybody can agree to and that are understandable to the general public. I mean I went to Hazelden in 1989 and relapsed as you know but you can't argue that some of what Hazelden gave me in '89 didn't ultimately pay—pay off down the road. Technically I guess relapsing out of there I would be considered a quote "failure." But that's some of what we wanna talk about today. What is outcomes? When we talk about addiction treatment, Dr. Klein, what is an outcome?
0:06:43 Dr. Klein
William, you can't talk about outcomes without really talking about both the disease of addiction and what that means, but also the—the bigger and the more important phenomenon of long-term recovery. Outcomes are focused on both. So, there's a lot of disagreement across practitioners, across the field, of what should treatment success look like. When somebody goes to addiction treatment, what things should improve? How should they be faring afterward? One thing that most people can agree on is that the person should not be using alcohol or drugs. Right? So abstinence really is in most people's minds thank goodness a prerequisite for that person to have a healthy, functioning life once they've been through treatment. Now how abstinence is measured and when it's measured and with what instruments and all of that, that's you know more detail and we could talk about just that subject for a very long time. But it's really important for Hazelden Betty Ford to have an opportunity to educate people. There isn't a really short, simple answer to that question. Because we define outcomes in terms of healthy recovery. And healthy recovery is a really large thing. It encompasses pretty much every aspect of that person's life. So substance use and not using substances is a—a necessary thing, but there's so much to people doing well than just substance use. So that's where you get into you need to be measuring their quality of life, their social relationships. Marv I'm sure can add to this. How are they taking care of themselves? So a lot of folks that present with addiction are also struggling with other co-occurring we call them co-occurring mental health disorders. Things like anxiety and depression. Those conditions also require long-term management, long-term care, seeking out professional services. So part of healthy recovery is—is that person taking care of and getting long-term help for those conditions as well as the addiction.
0:09:13 Dr. Klein
But recovery is so complex and so multi-faceted, outcomes measurement needs to be a reflection of a lot of different domains. So—so that's where I think Marv some of the disagreement and the arguing can happen but then the other piece of outcomes measurement really is just that you—you're always looking. Like the person is always carrying you know that disease with them and so—so you don't wanna just look while they're in treatment or ask them some questions once they leave. It's really you know up to everybody who has contact with this patient as they progress through their life to be accountable for learning about the care that they're providing.
0:10:03 William Moyers
Marv, what is a successful outcome? In the context of the fact that addiction or substance use disorder is a chronic problem?
0:10:11 Dr. Seppala
So the easiest way to look at it and—and Audrey referred to it is abstinence from psychoactive substances or intoxicants. And—and doing that over a period of time allows for all these other things in regard to person's life to come around as well. And the way I look at outcomes if we don't measure outcomes, we don't know if what we're doing is worthwhile or not. We don't know if when we make a change if it improves the situation or you know makes it worse for our patients. And our field developed separate from the rest of medicine. And yet in every other medical specialty, they have pretty standardized outcomes that they you know basically live by. And they treat people and they measure those outcomes so they know if what they're doing meets a certain standard or exceeds it and if not, they do the things to get there. And in our field, since there is a lack of standard, we can't do that. We can't determine if—if what we're doing is fantastic, if it's mediocre, if it's poor, and we can't compare to other programs and as we write these things up, we—we can describe what we've done, we can describe the outcomes we measure, and look at research literature that—that addresses that. But we don't really have other clinical you know peers to measure against to say you know you guys are doing a great job or you're just not meeting the mark. And that's really problematic.
0:11:42 Dr. Klein
Marv, I would also add that that same problem exists at the patient level. Or the level of a healthcare consumer, right, or a person that's looking into hey maybe I have a—a problem. A substance problem. Or maybe a loved one does. People that are looking into treatment programs they don't have a lot of information to go by, right. So other illnesses like diabetes, heart disease, you can go on a website, several websites, and people are graded. Providers and hospitals receive they—their measured on the same things, they get graded, they get evaluated. But a consumer or a person that's interested in getting treatment is making an important decision based on very little information. So again from the business perspective from a customer perspective, it's really challenging for folks to make an informed decision in that respect.
0:12:37 William Moyers
Well and in fact, the only information that a lot of consumers, people looking for treatment, the only information they find is what they see on those ads in the middle of the night or so where people are claiming or organizations of the advertisers are claiming a hundred percent success rate. Is it realistic, Dr. Seppala, to expect a hundred percent success rate in addiction treatment?
0:12:58 Dr. Seppala
No, not at all. I mean, maybe it—even during addiction treatment, a hundred percent's probably unlikely because of the potential for people to you know sneak in drugs or sneak in alcohol and use during the course of treatment. So, even there it's unlikely but especially over time, in a general way, if you're in the 50 to 60 percent level of abstinence, total abstinence at one year you're during a very good job. And to suggest 90 and a hundred percent abstinence rates is really unlikely.
0:13:32 William Moyers
And actually deceiving too, right—
0:13:34 Dr. Seppala
0:13:35 William Moyers
For those organizations that make that claim.
0:13:37 Dr. Klein
0:13:38 Dr. Seppala
It's great marketing, it's probably not accurate.
0:13:39 William Moyers
It's great marketing.
0:13:40 Dr. Klein
And one of the things William that I am somewhat fond of doing is just encouraging people like go back to the source. So if somebody's on TV at 2 o'clock in the morning, we have a 90 percent success rate, there's some simple questions that anybody can ask. Who? Like 90 percent of who?
0:13:59 William Moyers
Of what? [chuckles]
0:13:59 Dr. Klein
Who did you talk to?
0:14:01 William Moyers
0:14:02 Dr. Klein
What—what kinda care did they get? How did you reach them? What kinds of questions did they answer? When you start to probe into where the statistic actually came from, it can be pretty interesting and sometimes you don't get very specific answers.
0:14:17 William Moyers
To your point about the source, nevertheless the Butler Center for Resour—Research one of its core efforts is in the area of measuring success or outcomes, how do we do it? How does Hazelden Betty Ford do it?
0:14:33 Dr. Klein
The Butler Center for Research has a group of individuals that do patient outcomes research all the time. So we have a dedicated center where every single day we're calling patients on the phone, we're asking them a series of questions, we're recording that information very carefully, and I have other very gifted people that are analyzing that information and sharing it with the world. So we share it with the world, we share it with scientists in the form of publications. Anybody who's listening to this can go to hazeldenbettyford.org, our corporate website. If you click on Education, you'll see another screen. Click on Butler Center for Research there's a ton of materials that you can access and read on that page. One of those is a research update on our patient outcomes. It shows you statistics and numbers and graphs and talks about how we collected the data and of the people that we treated, how many people were we actually able to get a survey from. Which is a question we get a lot. We're so transparent and so clear about that. Because we want people to understand what we're seeing so that may—they can make an informed decision. But we also don't want people looking at one of our statistics and saying I wonder where that came from. So they're able to really know through accessing a wide variety of materials on our site. And even giving us a call if they want to on how—exactly how we do our research.
0:16:18 William Moyers
So the bottom line is and we all know this from our work people oftentimes will come to us and ask for help and they wanna know what they can expect and I oftentimes quote our own numbers and people look at me like ‘That's all the success rate is?' They're like [makes surprised face]. So tell us a little bit about what is success at Hazelden Betty Ford look like.
0:16:38 Dr. Klein
Yeah and that's another great question that I get a lot and we talked about that a few minutes ago. Oh, we have a 90 percent success rate. What do you mean? Define success. What is that? So, success I think should be stricken from the mention of outcomes. Right.
0:16:58 William Moyers
0:16:58 Dr. Klein
It's too vague. It's not useful. It's not helpful. So, if we define success in terms of the percentage of patients that we treat that are continuously abstinent from alcohol and drugs after treatment at about nine months, so far, in the folks that we're looking at in adult residential, it's about 70 percent of our patients. Marv talked earlier about addiction is a chronic illness. In many cases even in people who do achieve recovery eventually, it's often characterized by relapse to substance use. Given the reality and the medical nature of this chronic disease, people are going to—to resume substance use after treatment. So, what Marv said is absolutely true. It's not realistic to think that 90 percent of the people that you treat are gonna get so—sober the first time. That first year of treatment. And people should be a little bit skeptical of people that are making those claims. At the same time, we want to make sure that we're measuring other aspects of patient functioning. The other thing I will throw in here William 'cause I think it's relevant—the other thing that we do that's fairly easy to do is you can do what we call a pre-post. Right? So pre is what was the patient doing before Hazelden Betty Ford? How were they functioning? Were they using every day? Were they injecting heroin? Were they using multiple substances? Were they holding down a job, were they getting treatment for their anxiety or their depression? We learn about that too when they get to treatment we measure that. Because of the work my team does after treatment and collecting the same data, we can actually look at whether the patient has improved. So, when you say what's your success rate I say well part of answering that is where were they before and where are they after? Because the extent of the change there is often really dramatic and that's indicating that the patient is doing better.
0:19:22 William Moyers
What about Dr. Seppala—what about relapse? Does relapse equal failure?
0:19:28 Dr. Seppala
No. Even though I use that word in regard to myself, it's usually we—we'll call it treatment failure and blame it on treatment actually. That if people do relapse especially this day and age I mean we look at maintaining involvement with our patients for long periods of time. You know. Residential treatment followed by day treatment, intensive outpatient, long-term care and—and so in the course of that, if a person does relapse, we have to look at what we've been doing and where we may have failed that individual. Not blame them for some sort of you know personal failure. And it's really a part and parcel of this disease. Relapse is just a natural aspect of it. And sometimes, people really actually gain from relapse. They gain a recognition that they may not have had in an initial treatment because you know—
0:20:22 William Moyers
0:20:22 Dr. Seppala
They're faced with something new. I have this disease that I really didn't think I had, I didn't know what was wrong, I knew something was wrong but then they tell me I'm an addict and an alcoholic or something and I gotta do all these things and I'm not sure I really buy it. And I'm sure I can control it. Right? So they go out and they try that and it doesn't work. And it proves to the individual just the—the depth of this disease and that it—they really do have it. So sometimes that proof is necessary to finally you know really get along into recovery.
0:20:56 William Moyers
We know in these podcasts people are listening or watching and they might wanna glean something relevant as it relates to a family member, but more often than not, they're listening or watching because their struggling themselves. And they're somebody who's experiencing this conversation right now and they're in relapse—what do you tell them?
0:21:17 Dr. Seppala
You know, I tell—this is a brain disease, this is like Audrey said, it's a chronic brain disease. And you're always gonna be at risk for relapse. And it's really hard to recognize that without help from other people. I mean, sometimes the individual can recognize it, sometimes they can recognize it but can't do anything about it. And—and with the help of other people, things get much clearer. Because it since it's brain disease it undermines our ability to really see it for what it is. And we refer to that as denial but it's way more than that, there's actually alterations of parts of the brain that would usually recognize the problem and help us make a plan to do something about it. And—and without that functioning well, we're—we're at a real disadvantage by ourselves to get there. And so you know if someone's in the midst of relapse, find help, get help. Doesn't have to be at a treatment center, it could be elsewhere. It could be an individual, it could be a church, it could be getting to Twelve Steps meetings. Anything just to start down that path and get back you know in the direction of recovery.
0:22:25 William Moyers
What is it gonna take, Dr. Klein, to—to have our field rally around this set of common data points or benchmarks for recovery? Oftentimes, people define you know their recovery simply by abstinence and there's certainly nothing wrong with that as you pointed out abstinence is paramount to a lot of people. But there are many pathways to recovery as you said. How does our field come together to get these benchmarks that we can then communicate to the public at large or the consumer?
0:22:55 Dr. Klein
Well the obvious answer to that, William, one of the first answers would be for us to if we're not willing to work together, generate within our organizations, the willingness to reach out to one another and to collaborate. And be willing to do that. I will mention a project that we have been involved in that's close to finishing up. It—maybe it has finished up, "NAATAP" or N-A-A-T-P The National Association of Addiction Treatment Providers, is a leading organization in our industry. Hazelden Betty Ford has recently worked with them and several other addiction treatment providers to do an outcomes pilot study, where we're all measuring the same thing, we're all conducting the study within our individual sites and sharing the data and talking about the data. We're looking at the data now that is that was fairly successful in terms of the number of us that were willing to participate. That's one initial concrete step that proves that some of us are willing to collaborate.
0:24:09 Dr. Klein
But I wanna throw out a challenge to the other, let's call them stakeholders, in the health care space. Stakeholders are our federal government, our policy makers on Capitol Hill, our insurance companies that are paying for care. All of those are huge stakeholders in people being well and healthy in addition to the providers like us. Behavioral Health providers and other stakeholders need to be held accountable for demonstrating and measuring the impact of care. We're seeing that with acute physical illnesses all the time. Marv has already talked about that. So, we need to see people providing the same pressure and the same motivation and the same incentives across the health care system for that activity to be applied to mental health and addiction issues. And until that pressure and that accountability is there and articulated and being enforced by those groups, I don't see that providers are gonna have a whole lot of motivation to move forward.
0:25:24 Dr. Seppala
It's interesting that like orthopedics they have a repository of information about outcomes of you know hip replacement, knee replacement surgeries, all these different surgeries.
0:25:33 Dr. Klein
0:25:34 Dr. Seppala
And they have all this outcome data associated with them. And you could go to it and pick your surgeon and pick one of the best surgeons in the country based on that information. You cannot do that in the addiction field. And—and when you have that ability, it actually all boats rise because those surgeons are looking at everybody else too and all the other surgeons saying okay I wanna get as good as that. [chuckles] I do not want to be down here in the mediocre range. But if you think about it, as surgeons in general fairly big egoed guys, right, and women, and they didn't do this willingly. To say—I mean at some point—
0:26:13 William Moyers
0:26:13 Dr. Seppala
They had a lot of motivation to do it, but it took external pressures to get them to start this process and nail it down. And I think the same's gonna be true in the addiction field. And I don't think it's any more difficult—
0:26:29 Dr. Klein
No. It's just applying to a different area, right? And insurance payers have the ability to really move this forward. Pay for performance has been in existence for acute physical conditions for chronic illnesses for a very long time. So to Marv's point, it's just taking a set of processes and incentives and systems and applying them to the delivery of behavioral health. And boy if we can get some—some folks mobilized in that common effort, we all have the same goals, William. I really think. That triple aim, right, from the Institute of Healthcare Improvement. The patient, the population and the cost. And that all comprises the value of we want healthcare to work for people. We want people to get better. Everybody in this equation has that motive I think but it's what are you gonna do about it and how can you take some of these practices that are well dialed in in managing other chronic illnesses and applying them to behavioral health and mental health and addiction. It can be done, but there needs to be more incentive there.
0:27:40 Dr. Seppala
0:27:41 William Moyers
Our colleague, Lisa Stangl was telling me that we have about 90 seconds. So, Marv I'm gonna give you the last word here as it relates to outcomes and how they apply to your own journey. You—you shared with us at the beginning of—of this podcast that you've been walking this walk for 42 years now. And you were what, 18, 19 years old when you started the journey? How would you, for our viewers and our listeners, how would you define the outcomes that have mattered in your own journey as it relates to from the day you—you kind of came to terms with this problem to this moment?
0:28:18 Dr. Seppala
So it started with abstinence. 'Cause without that, I was a mess. [chuckles] And I couldn't get anywhere. I couldn't get any foothold to move forward in my life. And—and—and with abstinence, it gave me opportunity to start to change. And—and become somewhat of a different person. I mean, in my addiction, I dropped outta high school, I was disowned by my family, I lied constantly, I was a thief. It—I mean, it was a fairly, you know, bad existence. I did not like myself. I probably more fairly I hated myself. And—and so, outcomes being re-establishing relationships with other people and not you know just being the center of my own universe. And—and starting to live a life I could be proud of and—and happy with. Instead of you know hating myself. And getting on with a job initially and then an education completing college, going on to medical school. And developing a career and—and along the way, getting married and having two children and you know there's all these different aspects of outcomes in a successful life I think that go along with recovery from addiction. Because our bottoms can be pretty darn low. And to see those kinds of changes in people's lives when I meet with patients that that's what is really fun about this work. That—that—there's such dramatic positive changes in people's lives and I've experienced it, you've experienced it as well. We all have. And—and to see that daily is wonderful.
0:30:05 William Moyers
Well and to that point I think the finest, most important outcome for those of us who've been walking this walk whether it's 30 days or 42 years, it's the ability to give back to other people. And help other people. And I can't think of two people who who best symbolize that than you two in terms of you—you have this intellectual capital up here. You have this incredible knowledge and research in science and medicine. And at the end of the day, you have this passion for the mission at the Hazelden Betty Ford Foundation. A passion that has resulted in—in other people finding the answer. And getting that outcome that we all strive for. So I wanna thank Dr. Marvin Seppala, our chief medical officer, and Dr. Audrey Klein, our executive director of our Butler Center for Research. Thank you both for bringing your expertise, your knowledge, and your passion to this podcast today. On behalf of the Hazelden Betty Ford Foundation, I'm William Moyers and I wanna thank our viewers and our listeners for joining today and to continue to tune in to this Let's Talk series of Podcasts from the Hazelden Betty Ford Foundation. Thank you.