No one argues that the American addiction treatment system is anywhere near optimal—even its cheerleaders recognize that there’s miles to go before all people with addiction have access to respectful, ethical, effective and evidence-based care.
Worse, the past year has seen myriad media exposes and financial, sexual and maltreatment scandals.
Unsurprisingly, Marvin Ventrell, executive director of the National Association of Addiction Treatment Providers (NAATP), an organization that has represented rehabs like Hazelden and the Betty Ford Center (now merged) since 1978, doesn’t see the need for such an extreme makeover.
However, even he says that the industry is at a “crossroads,” and “we have bad actors out there.” He adds, “If our procedures for self-policing and transparency aren’t improved, the industry is going to be seriously harmed.”
With the input of longtime leaders in and critics of the field, here are my views on what needs to change
- Remove 12-step-related content from treatment—or at least, stop charging for it
In no other mainstream medical or psychological specialty are patients told that the best treatment for their disease is surrender to a higher power, confession and prayer—and, often, that if they don’t accept this method, the only alternative is “jails, institutions or death.”
And in no other area of medicine do insurers pay for hours of group “therapy,” films and lectures that consist overwhelmingly of indoctrination into the teachings of a self-help group, available for free in church basements.
Currently, at least 80% of American inpatient and outpatient drug-free rehab is dominated by the goal of getting patients to accept the ideology of 12-step programs and to attend as aftercare. To my mind, while 12-step programs do help some people, there is absolutely no reason that taxpayers or insurers should pay for the exact same social support and information that can be had for nothing at meetings.
- Ensure access to maintenance treatment for opioid addiction
In any other area of medicine, if patients were not informed about a treatment that cuts mortality by at least half—while being given one that has no effect on it—it would be considered malpractice
As National Institute of Drug Abuse director Nora Volkow put it in testimony to Congress last year, for opioids, “treatment programs with an abstinence focus generally do not facilitate patients’ long-term, stable recovery.”
Given this, stigmatizing maintenance or telling patients that it is “not really recovery,” is basically killing people
- Fight corruption and unethical practices
In the past year, the addiction treatment industry—never trouble-free in the best of times—has been wracked by scandal. A New York Times front-page exposé revealed sickening conditions, kickbacks and even forcing addicts to relapse to stay housed in supposed “3/4 houses” in the city. The Huffington Post (disclosure: I’m interviewed) published an in-depth investigation of how people with addiction in Kentucky are mistreated and denied access to MAT.
Buzzfeed investigated overdose deaths, kickbacks and overcharging for urine testing in Delray Beach, Florida “sober living” homes, which were also the subject of 2014 FBI and IRS investigations. The Los Angeles Times revealed that the owner of a network of LA rehabs was being investigated by the state and the FBI, for, among other things, sexual relationships with patients, poor care and fraud. And that wasn’t all. Longtime industry leader and Beyoncé-favorite Phoenix House was also investigated by Reuters for a patient death, for running facilities led by abusive staff and filled with drug use, assault and sexual violence, and for financial mismanagement.
Even the industry group, NAATP, wants federal regulation to ban practices like “patient brokering,” in which rehabs and sober living homes pay kickbacks for referrals to each other, without regard for whether a facility or service is appropriate for that patient. While the practice is illegal in some states, it is not against the law on the federal level. As Ventrell says, “It should be.”
- End the reliance on criminal justice system referrals
the treatment industry has for too long relied on referrals from the criminal justice system to stay solvent. Because at least one-third of treatment slots—and in many programs up to 80%—are occupied by people whose only other alternative is prison, the industry has had little incentive to make itself warm and welcoming
Several problems result. For one, since their biggest customer is often the criminal justice system, many programs shape themselves to its dictates.
Secondly, if a large proportion of the people in a treatment center have been forced to be there and only grudgingly participate, this can interfere with its ability to create a “safe space” for others.
- End humiliation and confrontation
It’s been known for decades—as I showed in-depth in my 2006 book, Help At Any Cost: How The Troubled-Teen Industry Cons Parents and Hurts Kids—that confrontational and humiliating “attack therapies” are ineffective and often harmful.
Unfortunately, nearly all long-term residential treatment centers in America— i.e., “therapeutic community” programs that last three months or longer—were originally modeled on a destructive cult called Synanon.
Synanon was founded by an AA member who believed that the steps needed to be applied by force and that people with addiction needed to be broken down completely before they could recover.
Phoenix House, Daytop and Delancey Street were all directly modeled on Synanon—and any program that uses “marathon” therapy groups, “pull ups” (confrontations), makes patients wear degrading signs or outfits and has a hierarchy of positions through which patients rise towards graduation has its roots in Synanon, either directly or indirectly, through staff training. And unfortunately, these methods are also favored by some staff at 28-day rehab programs or intensive outpatient treatments.
While many have moved away from the most extreme tactics, a widespread belief that all people with addiction are lying “whenever their lips are moving” and a sense that negative experience is necessary to get people to realize that they need to change remains common
More confrontation tends to lead to more drinking and drug use, not less.
- De-emphasize residential treatment
Many people believe that since celebrities go to exclusive spa-like rehabs, this is the most effective type of addiction care. But the data doesn’t support this. “Staying overnight together confers no outcomes advantage,” Willenbring says, adding that research on learning shows that people do not transfer skills acquired in an isolated setting back to their daily lives where they are most needed.
- Create truly independent accrediting bodies that are consumer-friendly—and national standards of care
This is where program accreditors like the Joint Commission and CARF are supposed to come in. Being accredited by at least one of these organizations is supposed to be a sign that the program provides high quality treatment and treats patients with dignity and respect.
Unfortunately, one of the most abusive programs I ever wrote about—Straight Incorporated— was accredited by the Joint Commission at several of its sites. And as late as 2007, a copycat program was accredited by CARF.
Further, in order to complain, consumers need to know which of these groups has accredited the program—and the accreditation process is still paid for and guided by the programs. Basically, this means that rehabs know in advance when they will be inspected for accreditation and that accreditors are financially dependent on the programs they are evaluating.
Given the fact that state treatment regulation is often lax and there are no federal standards even for basic things like counselor education, accreditation may be the only serious oversight some programs get
All counselors need to be educated about all aspects of addiction, not just their own recovery—and especially, about mental illness and what they are and are not equipped to treat without medical supervision.
- The Rehab Industry Needs to Clean Up Its Act
It’s completely outrageous that it took 27 years for the federal government to finally end its ban on funding needle exchange programs, which happened last December.
But expanding needle exchange to where it is needed across the country is not enough. We also need to start providing safe injection facilities (like this one in Canada, which cut local overdose rates by 35%) make naloxone as accessible as possible (including to opioid-addicted people leaving abstinence programs and incarceration) and integrate harm reduction ideas into the treatment system so that people who are not ready for abstinence have options other than simply continuing without medical care.