Best Practices and the Visible Horizon

To the Editor: It is hard to argue with Dr. Schreter's reply to the letter in the November 2004 issue that addressed the disconnect between so-called best practices and the funding limitations that often impede or even preclude their implementation (1). Nowhere is this more striking than in the recommendations of the 2002 Report to Congress of the Substance Abuse and Mental Health Services Administration (2), which promotes a longitudinal view of treatment for patients with co-occurring disorders despite the "caps" and limits on lengths of stay that are dictated by both state and federal funding.

The notion of "best practices," however, implies that nothing could be better and thus tends to limit progress in the field. After all, in the 1400s best practices included taking care not to sail beyond the visible horizon lest one fall off the edge of the earth. Christopher Columbus opted to ignore such consensus practices. More important is the identification of agreed-upon objectives and clinical outcomes toward which best practices may or may not be useful. Ultimately, it is the payers that determine what is worthwhile on the basis of their priorities. Treatment that works is always a good investment, financially and otherwise, if it is defined as having benefits that outweigh the costs no matter how high those costs may be.