3.1 Participants' demographic characteristics and counseling experience
As we have previously described (
Beitel et al., 2018
- Beitel M.
- Oberleitner L.
- Muthulingam D.
- Oberleitner D.
- Madden L.M.
- Marcus R.
- Eller A.
- Bono M.H.
- Barry D.T.
Experiences of burnout among drug counselors in a large opioid treatment program: A qualitative investigation.
), participants were 31 addiction counselors (18 women, 13 men) who self-identified as white (77%), Hispanic (13%), or African American (10%). Participants' mean age was 47.3 years (SD = 15.1 years) and mean years of counseling experience was 16.5 (SD = 10.7). Seventy-one percent of participants had a master's degree, 16% had a 4-year degree, and 6% had a 2-year degree. Of the remaining two participants (6%), one had a doctorate in a nonclinical field, while the other had a JD (law degree).
In response to open-ended questions about their perceived understanding, general perceptions, advantages, and disadvantages of the open-access model of care, counselors identified two primary themes—clinician level and client level—to describe the model's impact. Participants also noted two further themes—community-level advantages and program-level disadvantages. We identified subthemes (expressed by >10% of participants) from each line of questioning. Table 1
shows subthemes from questions regarding understanding and general perceptions of the open access model. Table 2
, Table 3
show subthemes from questions about advantages and disadvantages of the model, respectively.
3.2 Descriptions/perceptions of the open-access model
As described in our Methods
section, we prompted participants with: “APT uses an ‘open-access model’ of treatment. What is your understanding of what this means?” The following codes pertain to participants' descriptive responses.
3.2.1 Clinician level
When asked to describe the open-access model, many participants emphasized positive impacts on their own work experiences. For example, some participants responded to the description question with “It's great.” Other responses included a description of participants' working as part of a team-based approach. Few participants described the model as decreasing physical and structural boundaries with clients.
3.2.2 Client level
Counselors accurately identified the major components of the open-access model: enrolling prospective eligible patients rapidly into methadone maintenance treatment irrespective of ability to pay and providing multiple group psychosocial treatment options from which patients are free to choose (without making an appointment). Participants noted that immediate access to a range of services besides methadone dosing, including medical and mental health, defined the open-access system.
[Patients have] access to move around freely; to be part of the milieu. They have services available in the moment. It has reduced wait times for psychiatric and medical treatments … This is a place where they can come and there's not that division of us and them (Participant 25).
These themes suggest that counselors recognize the distinguishing features of open-access from the previous traditional model involving delays in prospective clients' accessing methadone maintenance accompanied by counseling delivered individually by appointment.
3.2.3 Community level
The provision of medical and psychiatric services to all-comers, especially those with higher symptom acuity and with fewer financial resources, was an important theme. Counselors perceived the open-access model as a method to broaden access to methadone maintenance treatment for community members regardless of resources and background.
3.3 Advantages of the open-access model
In response to open-ended questions about the advantages of the open-access model, participants described three themes: clinician-level advantages, client-level advantages, and community-level advantages.
3.3.1 Clinician-level advantages
Participants described the open-access model as a positive experience overall for clinicians. Clinician-level descriptions of the open-access model included that it required adaptation and a team approach in which clinicians supported one another rather than having individual caseloads. This resulted in counselors having limited client care responsibilities when they were out of the office (e.g., coverage when on vacation), which, in turn, allowed them to more effectively detach psychologically from work tasks.
There's no caseloads… you don't have specific patients on your caseload. It's rotating. Anyone can come in and speak to whatever counselor is available (Participant 27).
When specifically asked about advantages of the model, participants reported positive reactions (e.g., “It's good”; “It's great”), their own personal experience of the model (e.g., “I like it”; “I enjoy it”), and described positive personal or counselor outcomes of the model.
It helps the counselors. The responsibility is to focus on the client that's in front of you at the time…our main goal is just to meet clients' needs, where they're at, and go from there (Participant 22).
3.3.2 Client-level advantages
In describing how the open-access model worked for clients, participants reported that it increased and supported client autonomy, that it allowed increased flexibility to meet client needs, and that it was responsive to the needs and interests of clients.
With the open-access model, there's no appointments. When a person comes into the clinic they can be treated, their needs will be met… as soon as possible. They don't have to worry about waiting around that's what I see as open-access (Participant 18).
When prompted about advantages of the model, counselors described the reduction of barriers to enrollment as well as the ready availability of client services. Counselors described how clients have decreased difficulty accessing care in the open-access model compared with other methadone maintenance treatment programs and that clients have choice in the type of counseling services received.
If you're here for outpatient … you can stay for 6 groups a day, or you can come [for] one. It's treatment à la carte… the clients pick what they're interested in (Participant 28).
3.3.3 Community-level advantages
Respondents reported that the open-access model reduced barriers to care and that it served higher acuity clients. In contrast to the client-level category, this code reflected the broader impact of having increased treatment access for the community, serving as a treatment center where the highest risk community members could receive treatment, and having a clinical setting that was open to all (e.g., accessible time and location).
We're an organization that specializes in the treatment of addiction. We're here to help in any way that we can. Our doors are open. [People are] not turned away… [they] are given a fair hearing …[they are] not judged for what they're bringing to us (Participant 8).
Participants reported that the facility's open-door policy also led to an increase in high acuity clients being served.
[We] try and find a way to reduce barriers to treatment as much as possible. We work with really acute people, who are less likely to engage elsewhere, especially if there's any barriers to treatment … we reduce those barriers to try to keep them (Participant 26).
Participants described positive impacts on the community through the open-door philosophy and that the increased access to opioid agonist treatment reduced deaths, overdoses, and crime.
[Clients] talk about how years and years ago, how long it took to get in. The good thing is that it is saving people's lives in the community, so they're not on the street using or overdosing (Participant 17).
We receive a lot of patients into our program… in so doing we have (brought) down the crime rates. We help people to stabilize their lives and hopefully get a job (Participant 8).
3.4 Disadvantages of the open-access model
In response to open-ended questions about the disadvantages of the open-access model, participants described three themes: negative clinician-level outcomes, negative client-level outcomes, and program-level concerns. However, eleven participants (35%) identified no disadvantage (e.g., participant 5 stated: “There's really no disadvantages.”).
3.4.1 Clinician-level disadvantages
Counselors identified several disadvantages of the open-access model on their workflow, including that the workload can be uneven and that the demands are high because of the perceived unpredictability of the work. Some counselors also voiced concern that the increased patient volume led to a lack of available building space.
We have heavy volume … it can be unpredictable… even the building [is not able] to support the amount of people coming through here (Participant 12).
When asked to describe their understanding of the open-access model, some counselors expressed increased safety concerns due to perceived decreased physical boundaries with clients related to the increased volume of patients and lack of appointment-making.
There's a lot of people hanging out, there are, many of them spend the whole day here. They're loud. We can hear them in my office. They're distracting… I've lost 2 iPhones and my eyeglasses, and I'm blind as a bat! (Participant 31).
3.4.2 Client-level disadvantages
Counselors' perceived disadvantages of the open-access model to clients included its possible negative impact on the therapeutic relationship and difficulties with the lack of scheduled appointments.
It can feel chaotic… if someone can see a different counselor every time, they're able to fly below the radar. That's a concern here (Participant 30).
3.4.3 Program-level disadvantages
Counselors identified some program-related concerns, including that the model of treatment delivery needed to be more structured and intensive for some clients, although they did not delineate negative outcomes.
The only disadvantages I think … once they are in treatment there should be… a little bit more rigidity or more routine (Participant 9).