Q&A: What Really Goes on In Drug Rehabs

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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  The bottom line:  counselors with little education and less oversight are using outdated and sometimes harmful techniques; there are no national standards for credentialing or training counselors and most treatment centers, even those with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 centesr 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.

MORE: How to Find the Best Drug Treatment for Teens: A Guide for Parents

33 comments
LiamTurner
LiamTurner

I’m afraid drug rehabs are making money out of there customers is that real? Is there a proof that those people are actually, substance abuser in there life before they become like that?

LoraTrueblood
LoraTrueblood

I'll answer u Luifilipe...because everyone is different. I thinks it's bs how they treat us in there. I went down many avenues to become clean! I was less severe when I started and they put me on a hard drug called METHADONE! Don't ever recommend someone to that unless they r dying!! I got hooked so bad I withdrew from 2mg for 6 wks before shooting up again. Then I switched to suboxone. Couldn't tolerate that because I felt funny and the wd is just as bad. Then I went to rehab where they let me vomit and pee on myself and left my sheet that way the next 3 days before I was stable enough to check myself out and shoot up immediately! Fyi not one person in there with me was going to stay clean. I saw them out in the street a week to 3 weeks later depending on their release dates. I wanted to be clean so don't get confused. It's depressing feeling like the people who should Care and have the means to make you better dont! After 13 years of research I found IBOGAINE! ! I cry just thinking about it. It saved my life!! I have been clean ever since. And what I am saying is certain things work for certain people. Don't feel like there isn't something to work for you! You just have to find it. America doesn't believe on cures. They outlawed ibogaine even though it has been used for 50+ years for addiction AND mental issues

You will find, if you study addiction (I am a biomed major), that most have coexisting issues. We don't know which occurred first the addiction or the mental illness but it doesn't matter they both need to be treated. That is why I love ibogaine. It treats both and it's not a maintenance drug. Maintenance drugs are HORRIBLE! It is great as a last resort but let me tell you they shoot ur dose up so fast u can't ever come down. Out of all the thousands of patients at my old clinic I am the ONLY one that detoxed off it succesfully! My counselor told me that. He is the manager at my old clinic. So my point after my lengthy story is. Find what works for u. Don't go to rehab 13 times like my good friend did. It didn't work 2 times now u need to find something else. If you need time to look go on methadone and stay low dose and get the hell out as fast as u can! Fyi u have to sign a waiver if you want to go down more than 5mg a week!! Do what works for you. Ibogaine is a great alternative if you can get to Mexico like I did. Also Kratom can alleviate wd but can be addictive too so don't use it long.

LuisFilipe
LuisFilipe

I have a question – why have thousands of people being successfully reintegrated from outpatient centers, from TC models, methadone clinics, religion or no-religion facilities, and others by themselves?

JeanetteSnodgrass
JeanetteSnodgrass

I have worked in this field for 15 years, having become an LAC after a tragedy in our family.  I believed I could make a difference in peoples lives, and still do.  I wake up every morning, very happy to face the day in helping others understand their addiction process, and motivate them toward hope and change.  This is an occupation that takes strength, tenacity, faith, and belief in not only yourself, but in those you are honored to be a part of their treatment.      This is a very high burnout field...and yet "we", the counselors, are not recognized or honored, except by those who manage to turn their lives around and attain and maintain recovery...yet seldom is there contact with these individuals after treatment.   I find this article to be biased, reporting a "darkness and ineptness" to the field I have a true passion for.  I have worked inpatient, outpatient, in prisons, in methampethamine clinics, and with men and women of all cultures and backgrounds.  My peers are to be honored and supported. 

ChallengesRehab
ChallengesRehab

 I agree with much of what you said. The drugs used such methadone are effective and we use them all of our staf has exceptional credentials and yes there are a lot of rehab facilities that are staffed by untrained and certified personnel. We find it outrageous what other rehabs ar claming and this is a serious matter... you have someone's life in your hands. Than you for the great article.

CASAC-t
CASAC-t

I agree with this article and need to read your book. I just recently went back to college to get my CASAC-t or Credentialed Alcoholism and Substance Abuse Counselor designation in NY. I have heard the stories for years of people who have been in and out of rehab and I want to make a difference. I worked at a place for less than a year and was "let Go." I would look out side of the box and relate a persons culture to a concept of recovery. This idea did not go over well because it would empower a person were 12 step have you admit you powerless. Many old school counselors try to make a person completely powerless and this creates difficultly. To get back on track I was not liked by the rehab corporation but the clients loved me. I was greeted everyday at this inpatient. I gave each individual  an option to look at there "self" in groups. Also I tried avoid playing Father Martin videos (that younger people do not connect with) and bring in videos that I owned. They were up to date and honest. I tried to provoke "CHANGE" in a rehab and got booted because they were stuck in there old ways. That is one concept of addiction. I hope to find a place of work wants new ideas and are open-minded.

AtheisticallyYours
AtheisticallyYours

I am reading he book now, and it appears to be a 5 STAR TEXTBOOK, with ALL BASES COVERED! This book should be REQUIRED READING for ALL: insurance payers to "rehabs", government licensing agencies OF "rehabs", and anyone who thinks they can RUN a "rehab." And if you need one as a patient, don't even consider a "rehab" till you have read this book! 

BradPuckett
BradPuckett

I agree with her view of opioid treatment. My brother was addicted to pain pills and went through outpatient twice, along with one round of a 30 day inpatient stint and meetings galore. After 5 years of on-and-off drug use, he tried suboxone therapy along with an alternative treatment, Rational Recovery, and has now been clean for 3 years. He managed to go back to college and has plans for law school. He said he felt brain washed by the 12 step programs, and like there was no ultimate goal for him to reach in sobriety. I think certain addicts who inherently have over-achiever type personalities feel frustrated by 12 step programs, and need to have a sense of completion. AA and NA may not necessarily work for every single person. 

Break_Cycles
Break_Cycles

@thinkshrink @maiasz That was very interesting - shared it on my FB page - thanks for the heads up.

juliehuney
juliehuney

I agreed with the comments from Lernermd, the interim medical director at Sierra Tucson,  before even reading that was the facility where he presently works. You are right, Jerome, but my daughter was dead from an overdose less than four months from having stayed at Sierra Tucson. She died in March of 2010. The greatest downfall of any treatment center is the short-term length of treatment. My 20 year old daughter could not recover from a debilitating substance abuse problem in 30 days of treatment. There have to be long-term approaches to wellness and recovery that incorporate longer stays in facilities. I am sure the success rates must be much lower in short-term rehabs and intensive outpatient centers in comparison to longer term treatment centers. Of course, that guarantees more patients.

Although I learned so much the week we flew out for family therapy, it was too little too late. We have to involve families and communities to make a difference for those who suffer from addiction. Too often, as a very concerned mom, I was turned away because of privacy laws when I was desperate to help my child. I wanted to be involved. I wanted to help, but the only thing usually asked of me was my checkbook, and that's a travesty.

And in reference to being appalled by the resistance to maintenance treatments; don't be. They certainly are not a one size fits all, either. Our daughter was able to use Suboxone as a holdover until she could get her opiate of choice, as well as sell it to use the money to get what she needed. An opioid replacement is still an opioid. It just created a whole new set of headaches for us, and truly just served as a way for the pharmaceutical industry to legally sell to addicts.

BorisIII
BorisIII

I was required to see a Licensed addiction masters counselor.  She was burned out, didn't like any of the clients but the gay guy.  Only did bachelor counseling.  Mostly substance abuse education.  And what she talked about would only be believed by 5th graders.  Like if you smoke weed you will die or become an addict.  right after showing a film that 90% of baby boomers smoked weed. etc. etc.

THENONCONFORME1
THENONCONFORME1

@TIME @TIMEHealthland Reality most rehab programs will fail, with repeat offenders, still if one doe's not admit one's acts as being sinful

caesarcleo
caesarcleo

@time @timehealthland not enough proper counselling to help addicts. Not suprised at all. Will read.

breesuez
breesuez

What really goes on in rehab? “@TIME: Drug rehabs: The good, the bad and the ugly | http://t.co/H2xti4UT (via @TIMEHealthland)”

Lernermd
Lernermd

As a physician working with addictions, I find that many of the patients we see today not only have substance use disorders, but also suffer from major depression, anxiety, trauma,chronic pain, etc. I find it essential to have patients participate in a program that emphasizes individualized care. Group therapy is certainly a useful component, but one to one therapies are crucial as well. My experience has been that patients who participate in a 12 step process as well as receiving individualized treatment for their co-occurring disorders benefit greatly from treatment. Additionally, encouraging a healthy lifestyle with regular exercise, good diet, and a self-calming practice such as biofeedback or mindfulness, allows patients to leave inpatient treatment with the necessary tools to deal with life’s stresses without again turning to drugs to cope. 

Jerome Lerner, MD Interem Medical Director at Sierra Tucson    

jaypsyd
jaypsyd

No doubt there also were many worksheets. RT @medskep Q&A: What Really Goes on In Drug Rehabs http://t.co/UxAsV0yx Author@maiasz

Tbiosensors
Tbiosensors

@DrAlexConcorde Quite disturbing report

MarijAWanna
MarijAWanna

@maiasz If you would like the story of someone who went to rehab and is using the information they taught him against the same people who insisted he be in there, please get in contact with me. I feel what I have to tell you might be of interest to you if you intend to delve into this topic further.

jeff_deeney
jeff_deeney

@maiasz The confrontation thing I also don't see in treatment centers but have seen in halfway houses receiving paroled prisoners.

LoraTrueblood
LoraTrueblood

Show me ur data on outpatient because everyone in my outpatient either never got clean or was clean for max 10 days lol!! Unless u have additional help that is such a bs place to go! It's so damn boring. We did finger painting! That have no clue what to do with u in there...u sit around a stupid table in a classroom and talk about the same ish for DAYS! most of the students shot up before class just to avoid boredom!

LoraTrueblood
LoraTrueblood

I don't know who u r trying to fool but those places suck so bad! How bout u tell my friend how honored u r. Why r u taking this so personally. I think that's ur problem it's not about u. It's about them. U need to be helping people that need help. To be honest I don't believe u can. U don't need a degree or any formal education to know how to treat an addict now a days! Any idiot off the street can do it! My step sister had sex with one of the workers in the laundry room on hall! U have no clue what goes on in these places!

FrancesFarmer
FrancesFarmer

@JeanetteSnodgrass  Oh boo hoo, you aren't honored or recognized.   Neither are nurses or teachers and we have degrees.  This article is spot on and I want to thank you for completely proving the author's thesis with your comments.  Rather than considering what the author had to say, you have immediately jumped to the defensive, justifying and rationalizing a treatment system from which you seem to derive your reason to live.  The treatment industry in this country is a joke, and will soon be outed for the corporate money sucking hole it really is.  But you just keep on keeping on and face everyday happily.

LoraTrueblood
LoraTrueblood

You r crazy! Methadone is the DEVIL! Until u r forced to take it and get off it then I have no respect for ur opinion!

LoraTrueblood
LoraTrueblood

He isn't clean...bet if he misses his dose of subs hell b shooting up cuz he still addicted to opioids. What a joke people. These drugs were made to be on for 7 days max and the big pharm figured out another way to make money off us addicts! O fyi sub wd is wayyyyyyy worse than pain pills or H

Just ask him to skip his dose for a cpl days or what's he gonna do when he loses his insurance guess hell b back on the street. Clean is clean. Been there been told that bs lie! I did both subs and methadone. He's still an addict.

maiasz
maiasz

@jeff_deeney interesting. it always seems to pop up somewhere, unfortunately.

jeff_deeney
jeff_deeney

@maiasz Worth your looking at. There's a "rehab" system inside the correctional system that's pretty off the map. Let me email you on it.