My concern in discussing treatment in public like this is that I might somehow discourage someone who needs help from seeking that help. That’s part of my decision to explain a different side to Alcoholics Anonymous, from a perspective I didn’t have ten years ago. If someone is in need of help for a drinking or substance use issue, I would hope to support that decision by encouraging them to seek help in any way, shape, or form that could serve to potentially benefit their recovery. But I’m not coming from a position, personally, where I feel like there’s tremendous value built into the established treatment model. This isn’t because I think rehabs (in the most broad and general terms, at least) can’t help people get sober, however, but has to do with how the expectation for what they are and how they might actually be of help to the recovery process is where their value becomes most distorted.
What I mean by this is that the expectation set by the industry, surrounding what realistic outcomes can be produced by a short-term intensive treatment program, is largely misunderstood, with rehabs banking on the relatively uninformed nature of those seeking help to keep their doors open. In the 2020 National Survey of Substance Abuse Treatment Services, there were over 18,000 treatment facilities recognized in the United States. Roughly 50% of those facilities included in the final report were identified as private non-profit organizations, while about 40% were recognized as private for-profit organizations. To be up front, the distinction doesn’t make a whole lot of difference to me; the top eight salaried individuals at the first treatment center I worked at, which is a non-profit, shared a combined payroll of over $1.3 million in 2020.
There’s a 2018 episode of Last Week Tonight with John Oliver focusing on rehabs which digs into the treatment industry’s problematic underbelly. Within the episode, Oliver does well in questioning a lot of relevant aspects of treatment, but an area he goes deep on is one I also want to draw attention to, dealing with the credentialing of professionals in the space who work directly with patients. In the state of Tennessee, for example, there is a licensure process specifically geared toward those counseling within the alcohol and drug field (referred to as Licensed Alcohol and Drug Counselors, or LADAC for short). The educational qualifications for this basic license is a high school diploma or GED. I’m not saying that education alone makes for more qualified group of professionals, but I bring this up to point out the variety among what it means to be considered a professional and credentialed counselor (the term “therapist” is largely interchangeable, but I’m going to use the term “counselor” here). All through my own master’s program my professors repeatedly communicated that they and the program were working as “gatekeepers” for the mental health industry, but even through my own internship process my spirit took a hit related to how wide open that gate actually is. Circumstances surrounding my placement at one internship site led to me getting pulled from it by faculty after about two months, but while there I briefly worked alongside multiple individuals who were misrepresenting their credentials, including one counselor who had a criminal history resulting from theft from a homeless shelter they previously worked for. It’s almost beside the point that the office itself was under investigation from the Tennessee Attorney General’s Office for Medicare fraud, but the broader point of bringing it up is to speak to the inconsistent nature of mental health care when considering the professional qualifications required to serve in a therapeutic position.
Many more questions can arise when considering this sort of dilemma. Does a facility use the equivalent of LADAC-level counselors or are does it rely on master’s level practitioners who’ve achieved the requirements of an accredited graduate program? Further, did that master’s level student graduate from a program recognized by the Council for Accreditation of Counseling and Related Educational Programs, or a program that does not, which might not then meet state-level standards for licensure? Once graduated, is that counselor licensed to work independently or are they pre-licensed, working under independent supervision while they pursue state-level qualifications. Is the counselor actively working toward licensure, or just working at a facility under the general supervision of a site-supervisor. Does the counselor have much, if any, actual experience working in a specific diagnostic realm? All of this is important, and it begs to remind that credentials don’t guarantee competency; just because someone is employed as a counselor doesn’t mean they have the right level of education, training, or experience to productively assist with the problem at hand. I know A.A. members who are incalculably more apt as helpers when it comes to addiction treatment than certain professional therapists I’ve met. The current mental healthcare system is piecing together care as best it can, and I’m not trying to finger wag at anyone for the standards of care that have developed along the way. I am, however, trying to point out the incredible range in qualifications of those providing care and asserting a recalibrating of expectations relating to what mental healthcare professionals actually are, particularly relating to treatment for alcoholism, is in order.
First and foremost, it’s expected that counselors working within the alcohol and substance use space have an idea how to treat alcohol and substance use, but how they do that relies upon how the organization even conceptualizes the problem. One rehab might work under the pretense that alcoholism is a pattern of maladaptive behavior that requires a strategy of behavior modification to change, while another is founded in 12 Step principles. And regardless of what the facility’s stance on the matter is, individual practitioners are going to facilitate in a manner aligned with their specific therapeutic perspective; meaning, if a counselor believes 12 Step work is valuable, or they’re more familiar with 12 Step facilitation because of their own lived experience (again, recall how much of the population in the helping field might be considered “wounded healers”), that will be the lens through which individual treatment is guided. On top of that, however, counselors (particularly those working at in-patient or intensive outpatient programs) are expected to be equipped with skills to help with depression, anxiety, trauma, and polysubstance issues (which doesn’t even include crisis management and de-escalation training). And on top of that, turnover in alcohol and substance abuse counselors is high, which leaves its workforce relatively young in experience. This is another good moment to add that I didn’t even make it four months before quitting my position as a primary therapist at an in-patient program in Nashville, but on the staff of full-time counselors, not one of us during my time there had even two years experience in the position. Also, for half of the staff who were employed in a position similar to mine, that was the first job in the field they’ve had out of graduate school. This is all important because it impacts what treatment is. Rehab is broadly considered a process individuals seek when they want to get better from their addiction, but in reality it’s a place of emotional triage and physical stabilization.
I don’t want to demonize rehabs so much as use them as an example of how a broader system of mental health care is failing as a whole. One trend I saw in the facilities I worked for and with was a completion of programming based around an insurance driven variable-length-of-stay for patients. This means the duration an individual stays in rehab is aligned with what their insurance company will provide, and not aligned with any specific programming criteria at the rehab itself. From a business perspective, I understand the consideration when adopting a model aligned with what insurance companies are willing to pay for, but the implication of doing so is that there is no cohesive concept of what the treatment process is. If one person’s insurance company will pay for them to be in a facility for a couple days, while another person gets over a month of care, what does it really mean to say that either have “completed treatment”? It’s not that either has achieved a level of physical and emotional stability and are now ready to get back to their lives, it’s just that they physically stayed in treatment for as many days as insurance was willing to pay for. If someone leaves treatment before that, they’re considered going “against medical advice,” and may receive an “incomplete” designation on any reporting sent back to insurance, but it doesn’t mean they necessarily had any more or less group work, therapy, growth, or healing, than anyone else.
Treatment centers exist to help, but regardless of whether they’re technically for-profit or not, they also exist to make money. I can’t decry treatment centers for their role in a broader capitalistic healthcare market, but I can challenge what they propose to represent. Regardless of what specific rehab we’re talking about, they’re likely to rely upon a message that their approach utilizes evidence-based treatments, or perhaps that their program is grounded in a holistic approach to healing. Each treatment has some sort of secret sauce, even when they claim not to. They may blend treatment modalities in a novel manner or put their own spin on a “back to basics” 12 step approach. But they do it in their own way. It’s just that any of the secret sauce doesn’t in and of itself provide individuals with willingness or motivation to change; nor does it help with legal, employment, housing, relationship or any other problems that await a person once they have “successfully completed” treatment.
From the side of being a counselor I didn’t have a tremendous amount of faith that a position at a treatment center was right for me, so I left. After my prior positions in the field, I’d already sworn off working within the addiction world, but an interesting role came up and I went for it. When I did, however, I was reminded of how there’s so little time to work with individuals in the in-patient space, and when shut off from the rest of life, that leaves them no way to road-test many of the skills being developed while in treatment. Some patients sought out treatment themselves, willingly, while others were there to satisfy family members, a spouse, or an employer. I don’t recall where I read or heard this, but it hits the nail on the head with where I was at in that job. Someone once said, “I’m tired of dragging people to healing by the scruff of their neck.” Every single day in treatment it comes back to facing head-on individuals stricken with the sort of terminally unique mindset I’ve outlined in the previous chapters. And that’s a lot to deal with day in, day out.
One problem I have with segments like that from John Oliver’s show, however, is that they don’t seem to offer much in the way of an answer. A decade ago, I wrote about what I saw as a solution,
“What we need is a cost-effective, standardized model that offers hazard drinkers a stepped system of care, beginning with minimally intrusive interventions including basic health education, only graduating to more intensive and expensive treatment methods as required. What we need is reform to combat decades of directionless legislation aiding professional incompetence, leaving the well-being of countless vulnerable individuals in the hands of those ill-equipped with the knowledge, skills, and credentials necessary to provide a full range of evidence-based treatment. What we need is treatment and therapy that is responsive to individual circumstance and need, able to assess, treat, and medicate co-morbidity when it exists, and standardize proficiency implemented to help recognize when it does not. What we need is an environment encouraging a therapeutic alliance between patient and caregiver, rather than an unregulated model for healing that constructs problems to spur further unnecessary treatment. What we need is integration of alcohol addiction prevention into routine health care, removing its stigma, and separating disease-concept from disease-treatment. What we need is an educated legal system that promotes educated wellness over complacent ideals. What we need is to remove focus from success rates, instead developing an evolving process that speaks to the issues that have led to individual relapse. What is needed is ethically-centered treatment that is based on transparency from educators and legislators alike…”
This is a fantastic shopping list of modifications that would change the entire system, but it’s also absolutely useless in its lack of practical application. There’s not going to be some sort of unified theory of recovery that provides a robust and all-encompassing humanistic approach, because it’s just not possible within the society we have. The same problem I have with John Oliver’s video is one I have with my own conclusions a decade ago, because rejecting what exists is easily mistaken for helping create any sort of meaningful change relating to that problem. To take issue with and poke holes in the current treatment system fails to promote actually changing it, no differently than how my gripes over the innumerable flaws within A.A. did anything to affect it for the better. The point of treatment is not to cure anyone, but to stabilize individuals and potentially plant a few seeds of recovery, which may or may not take given the conditions that individual faces when they leave the facility. The same is true of Alcoholics Anonymous; it’s not meant to cure anyone any more or less than any other pathway of recovery. Both are only just a start.
[The track opening and closing the episode is called “styles.”]