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  1. BitterSweet
    18998.jpg In a new book, author Anne Fletcher reveals the good and the bad state of care in drug rehab facilities.

    Last summer, the National Center on Addiction and Substance Abuse at Columbia University released a report detailing the devastating state of addiction treatment. The bottom line: counselors with little education and less oversight are using outdated and sometimes harmful techniques; there are no national standards for credentialing or training counselors and most treatment centers, even those with extensive financial resources, do not always use best practices. In her book Inside Rehab Fletcher investigates the erratic quality of care in some of these facilities and how some centers are working to improve treatments. (Disclosure: I was interviewed and cited in the book on the subject of rehabilitation for teens).

    Why did you decide to investigate rehab?

    There’s a huge number of people with serious substance use disorders (SUD) and 22 million people in this country who have problems. Only 1 in 10 of them go for any sort of help each year. There’s all kinds of reasons why the other 9 don’t get help but it’s my impression that many people who don’t get help … are not happy with the treatment options out there.

    The public is greatly misinformed. They don’t know anything about rehab. There’s so much misinformation, so I thought that somebody needs to go inside and explain it to the public and talk to people who've been there so that’s what I did.

    What was the most surprising thing you found?

    The biggest shocker to most people is the lack of training of the people who provide the lion’s share of treatment, addiction counselors. In many states, they are not even required to have a college degree.

    Any other big surprises?

    I knew that addiction treatment is largely group-based but in visiting some of the high end programs where I thought maybe it would be more individualized, I [found the same thing]. I actually added it up and went through a typical treatment day. It works to be about 8 hours of day of seat time [in groups] and this is when you are paying $25,000-30,000 a month. I had figured that there would be more than three to five hours of individual [counseling time] a week, at least.

    So there were 8 hours a day of group or watching videos or lectures— and that has been found to be among the least effective treatments for alcohol problems. I really didn’t expect that much seat time. I visited outpatient treatment as well and some of those have no individual [sessions] at all or it is ‘as needed’ and even less than in the residential treatment.

    One of the things I found myself thinking as I was sitting in those programs was, ‘Whoever came up with a model where you take addicts and they are sitting for three hours or more three times a week or longer in group based treatment, talking about the program?’ That’s an awfully long time to just sit on your butt. I would ask, ‘Is there any evidence that this is effective?’ and no one could answer where it came from.

    Can’t you admit more people and charge more when you put them in groups than if you individualize therapy?

    It is cheaper. In all honesty, however, the places that I visited I really believe in what they’re doing. There are some incredibly compassionate people who believe they are providing the best treatment and they’re helping a lot of people.

    What else did you find that was disturbing?

    One of the things that really floored me was the resistance to using maintenance treatments [with methadone or suboxone] on the part of programs, when the literature is so clear that maintenance is the most effective treatment for people with opioid addictions. I had places say to me ‘We don’t use it because it’s a recipe for failure’ and it floors me that anyone can think that way [given the overwhelming data].

    A lot of addiction treatment in America is based on the idea that you have to “break” addicts, humiliate them and confront them until they confess their worst sins. Is it effective?

    I didn’t personally observe anything terrible. I kind of expected I might see some confrontation, but I didn’t see any overt confrontation. But the vestiges of that confrontational approach remain in the words that are used to describe people, like the stereotype that all addicts are selfish and manipulative and always lying, that they’re all the same.

    The worst thing I heard reported, and I did not observe this, but I was told about a place that treated indigent people, which was loving and caring [in the treatment itself.] But at night, [the participants] lived in sober homes and had to sit on boxes in the corner or wear [humiliating and degrading] signs around their neck, and that occurred in 2010. It’s still going on, including [the groups where] one person sits in the center of the circle [to be] shamed [by everyone else].

    There’s also a lot of pressure to emphasize very personal information in group, a lot of pressure to disclose secrets. While some people said that was very helpful, some said it was very unhelpful. Someone did talk about having to disclose sexual information in a group situation and was very uncomfortable with that and did better in individual therapy. The problem is the lack of an individualized approach and not recognizing that everyone doesn’t belong in a group.

    What about the 12-step approach, another common program in drug rehab centers. Is it effective?

    We need to move away from the one size fits all model. We know the 12 steps don’t work for many people. Fifty percent to 80% of people sent to [Alcoholics Anonymous] from treatment drop out within a year. Yeah, it’s great when it works and it works for people who affiliate and get involved, but most people drop out and they’re not being told about other options.

    So, do we have treatments for the variety of people who need it?

    One of biggest issues is that of those 22 million people with substance use disorders, the vast majority are not the kinds of people who belong in an addiction treatment program [as they are configured today]. The vast majority of people with SUD do not have severe addictions. There’s no place for these people and they often do wind up [in rehabs] and don’t fit and drop out or keep using until it does get really bad.

    We need to better educate all of our health and mental health professionals about SUD. Most people are blown away [to learn that] most psychologists don’t have any training in addictions Our physicians have very little training in identifying SUD, let alone treatment. And we need to improve the training of people working in the field itself. Most experts said that they thought that the minimum credential, as it is in most psychology [fields], should be a master’s degree, with the ability to critically review scientific literature and think critically.

    Where should someone who needs help for an alcohol or other drug problem turn to for treatment?

    First of all, I would suggest that if you can, get an independent evaluation from someone who doesn’t have any vested interest in any program you’re considering.

    The first knee jerk reaction is that ‘You gotta go to rehab.’ But if someone doesn’t have a severe life threatening addiction, for starters, find an individual therapist with mental health experience who also has experience with addiction.

    If you are going to go for help, don’t automatically think residential. There are a very small number of people who really need residential, typically people with serious co-occurring disorders who have been through outpatient and failed many times.

    What positive things did you find?

    Number one, the compassion in the field. They really believe and really want to help people. But number two, I did feel that things are changing and even among the programs I visited they were changing over time. I do think things are changing in a positive way towards evidence-based treatment but it’s slow and spotty.

    Author: Maia Szalavitz, Anne Fletcher, TIME Healthy and Family
    Date: February 15, 2013


  1. Pain Hurts
    Well done, said. I have heard tons of horror stories of these poor facilities and a local pain clinic once tried to label me an addict and have me fly over the cookoos nest instead of fixing or trying to target the source of my real pain. I refused to go and luckily found a doctor who is young but still I pass all drug and urine and other tests and remain living with some level of pain relief. At least.
  2. BitterSweet
    Yes I posted this article because it is so true - it seems the automatic answer to someone saying they are struggling with addiction is to go do inpatient rehab and that's the only way. Looking at the statistics of recovery rates for patients who leave the facilities after says a lot. Also, the article made a good point. Here is the quote in the article I'm referring to:

    Also, speaking from my short 3 day stint in a rehab facility here in Canada, it is just an absolute joke to believe a place like that is of any help, especially in comparison to all the options outside of inpatient, and with inpatient, you're paying thousands of dollars. A 28 day program is still expensive, and 28 days is an arbitrary amount of time expected to fit all patients.

    The facility I was in was one of the more reputable ones. Just like the article described, it was all group settings, the kind you would expect in one of those cheap government funded groups run by volunteers. We sat in a circle and went around the group talking about whatever. Then we did an activity where we had to walk around the room with a pen and paper and try to learn about the other people. We had 'class' at 8 am, and I was falling asleep, LITERALLY, and I was at the front, and everyone was chuckling at me. All I wanted to do was sleep, especially only being 2 days into coming off of long term amphetamine use. They were teaching some crap about ecstasy, and gave us a little work book.

    At night, they encouraged us to journal, and at group mandatory meetings, which consisted of sitting in a circle where they check to make sure you are there. Then you would have to say your name, saying that you are a drug addict, and pick one emotion for how you were feeling that day. Then of course they shipped us off to AA and NA meetings, which involved walking across town in the blazing heat, which was kind of weird they late us walk across town by ourselves. Then I had to sit through AA even though I had no alcohol problem, and at that time I was not really a supporter of the 12 step, and now I know I am definitely not.

    They gave us a timetable of when group meetings would be run. We had to go to a minimum of three daily. Then the rest of the day, basically 9 hours in total, we just had to walk around the facility and do nothing. It had a beautiful outside setting, but you can only sit in a chair outside before it's boring. There was tennis, but one old rusty court, and you had to sign it out. They had a gym, which was open for like 5 hours, and looked like a gym out of someone's basement. Their library was equally pitiful, with old school computers and the slowest internet connection that it myswell have been dial up.

    And to even enjoy these crappy things around the place, you need to at least find someone who you get along with. I felt like I was in high school again, trying to fit in. I already suffered from social anxiety, and I wasn't really interested in spending my days with people I wasn't interested in. Mostly everyone was older than me. It was also a facility for guys and girls, so there was pressure to look presentable around guys, coming from the standpoint of a girl who already has insecurity issues.

    At 6 am we would line up for our meds, and then at 8 pm go for our exercise haha which literally was doing stretches in the gym for 20 minutes or going for a walk. For the little time I was there, I mostly wanted to just go back to my room and sleep since the place was so depressing, but the nurses would come in and tell you to go do something. The rooms had two beds each, pretty much hospital style beds, and then there were dressers and that's about it. They didn't even check my bags coming in, which you think they would just in case I was smuggling a bunch of drugs in.

    Meal time was crap - picture a school cafeteria but 10 times worse. Then you get your food and look for a table to sit at that looks the least awkward. We weren't allowed to bring food back to our rooms but my room mate and I stole some peanut butter packets and crackers.

    The doctor on staff was the worst, oldest, meanest doctor I've ever seen, to this day. She had no understanding of addiction and pretty much shamed me the whole time I saw her, and did the same with the other patients who saw her. My real psychiatrist sent in a request to have a change in my medication and it took them forever, because the mean doctor wasn't there for the weekend.

    God, it was exactly like high school, down to the timetables indicating which room we had to go to for our group session. There was not even one individualized therapy session available at all. When I complained about this, they told me it was important to just get started with reintegrating into normal daily functioning. But um, I could have done better shit at home. The only thing inpatient provided me was the unavailability of getting drugs, but to get sober, you really need to want it. So if I was planning to get drugs, I'd just white knuckling it. That place made me even more depressed and made me feel like scum. The bathrooms were disgusting - I didn't have flip flops to wear so that was a hassle. I have like OCD issues with cleanliness and that just magnified my general anxiety.

    The nurses were just bitches. Oh, and there was a smoking section outside, reminded me of the smoking section out front of my high school when I was a teenager. Just bleh. It was supposed to be a program for people with mental illness and addiction, which was apparently different from just the addiction program, but not once did I hear mention of mental illness treatment plans in the 28 days.

    So on day 3 I knew that staying at that place was money wasted and a nightmare already, so I called my mom and told her what it was like. She came to pick me up, where the nurse kept telling me I was just acting on an impulsive need to get drugs, and for some reason when I said I was leaving and they could tell I meant it, they then said I was going through opiate withdrawal and that they could give me something to help me with that - umm, I wasn't in there for opiate withdrawal, and if I was, sure as hell wouldn't have been functioning at all while I was there. Anyway, then my mom arrived and the nurse started yelling at her saying that my mom was lonely and needed me in her life so my mom was sabotaging my sobriety because she was lonely, when it was the complete opposite - my mom was married, had a full time job, two dogs to take care of, one of them being a large breed, owned three other houses with tenants, had a shitload of friends, and it was more like I needed her as part of my social circle lol. Then the nurse tried to say my mom was also an addict when that was so far from the truth it wasn't even funny. Finally the nurse just yelled out, "your daughter is a drug addict and you're in denial!". So my mom and the nurse almost got into it, but I just wanted to get the hell out of there.

    Luckily there was some sort of refund policy, only being charged for the days there. I'm sure this policy exists for the many people who probably leave early lol. And then following this short experience in 2010, every 'professional' I've talked to automatically thinks that me leaving after 3 days is just an example of my wild addiction and my denial and me not wanting to get clean. When I explain the situation, it just sounds like excuses. The health field and the mental health industry need so much change to it that it's not even funny. The patients are treated like children and are on a lower level then the therapist or whatever the person claims to be.

    It's just a broken record for me anymore when I have to tell people inpatient is not for me - people think this is the ultimate solution and can't accept the fact that getting clean in other ways is possible. If anything, that is the reason why I automatically went to inpatient without considering other options. Now I know what works and what doesn't - group meetings, I need them but not 5 hours a day of them. Individualized therapy is a must, exercise, friends, etc. Learning how to be sober in my environment, rather than leaving the bubble institution and falling into the same old traps because of a triggering environment.
  3. Pain Hurts
    The broken record syndrome you mention, so true!!! , "health field and the mental health industry need so much change to it that it's not even funny" , from your post, is also the precise point I was focused on. I cannot even fathom going through this to be honest BitterSweet, and really do understand just how fukin traumatic this bullshit was, the people make the real difference, and these people were not a good fit. As a person with an HR & Management background from working and school and stuff when I look at this example and my horrific & almost life altering inhouse 1 week cleanse or jail time I get so upset. The system is broken and people who run it are morons, there are good people out there with the right training and skills, abilities, etc .... but wow. This is scary. Really.
    Did I mention the pain clinic I was referred to is a world class place, according to all the literature, and I knew they had no clue what they were doing and had 1 focus within 24hours of speaking to the moronic nurse and head of the entire goddamn place. They tried to have me pay out off pocket for physio and stuff, $200 per hour & then mixed up all my info and stuff. A overall disaster. They basically have a script or protocol to follow and try to cookie cutter fix everyone by the same method. Sell them , make them pay $ and then get them on methadone. Done. I was so angry I complained immediately to the appropriate people and got out... I dont wanna give too much detail.
    They even sent me to CAMH , to see a addiction doc who wa sa goof, a true moron, he never ever once mentioned or referred to my actual pain conditions or the source of pain, he only always spoke of how bad and evil these opioids and oxycodone and oxycontin was evil... over and over.... the goal was to get me onto methadone, and no longer term pain management or plan to help me, fix me, at all.
    I might have rambled a bit , you also obviously saw a similar pattern of incorrect and outdated and ineffective treatment, I will not even refer to these methods as treatment. a joke. and its real people and real lives they try to fix. And all they do to people is hurt them, injure, and I see why soooooo many people are homeless, refuse to see doctors, abuse hardcore and tons of drugs they dont even need.
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