inside rehab: findings from an author’s four-year exploration of the u.s. addiction treatment...

InsideRehab:Findings from an Author’s Four-Year Exploration of the U.S. Addiction Treatment System

© maxmitzu - Fotolia.com

“The Treatment Myth” – Minneapolis Star Tribune, 1993

“Chemical dependency programs exaggerate their success rates”

“Treatment has little scientific support” “For many clients it’s a revolving door” “Even an elite treatment program has

many failures”

Visits to 15 “rehabsInterviews w/ > 100 staffers, leading

experts

Review of scientific literature

Interviews w/> 100 clients

Conducting the Research

Goals – To… Give consumers a realistic picture of what

goes on in residential / outpatient rehab Uncover myths and facts about treatment Address issues faced by people in rehab and

by the industry Provide guide to different types of treatment

and ways to recover Inform consumers about science-based

practices and spotlight facilities using them Provide guidance for finding quality treatment

• What determines whether you should go to rehab?

• How do most people choose a rehab?

• How is rehab financed?

• Does more expensive tx = better tx?

• Who are rehab treatment providers?

• What do people actually do in rehab?

The Questions & the Issues

• How are co-occurring problems handled in rehab?

• How are family members involved in tx?

• What happens if someone has a slip in rehab?

• What happens after you get out of rehab?

• How do you know if a program is effective?

The Questions & the Issues

Myth: 30 days is long enoughMyth: More money buys better treatmentMyth: Group counseling is the best form

of txMyth: Drugs shouldn’t be used to treat a

drug addictMyth: To recover, most people need

treatment

Myths about addiction treatment in the U.S.

Myth: The 12 steps are essentialMyth: Highly trained professionals

provide most treatment Myth: Most programs offer science-

based approachesMyth: Most who go to tx go to overnight

residential rehabs.Myth: Upon relapse and return to rehab,

new approaches are used

One-size-fits-all approachesGaps between science and practice

What should protect us doesn’t

Key Findings

Group counseling for everyone“I don’t like groups—they make me uncomfortable. I have never shared in my life at a 12-step meeting. It seemed that my stories were way worse than others’, and it made me not want to share.” Sarah J.

Key finding: One-size-fits-all Approaches

Same assignments for all“It’s a cookie-cutter approach. I felt like I was part of a herd...Everyone seemed to be working on the same thing; we all seemed to be on the same path.” Elizabeth F.


12-step ubiquity“I personally do not know of a single program—other than methadone programs for heroin addicts—that could reliably be characterized as anything other than 12-step.”

Tom McLellan, Ph.D.


Private programs (2007-8) – nearly 8 of 10 offered 12-step-based tx or

included steps in program• 2/3 required 12-step attendance• > 50% held 12-step meetings on-site

Public programs (2009–10) ~ 7 of 10 based primarily on 12-step model or included 12-step component

National Treatment Center Study, U of Georgia

Studies show “a positive but modest association between AA attendance and abstinence.” Scott Tonigan, PhD

Individuals who attend AA frequently more likely to become & stay abstinent over short and long term.

AA involvement may substantially reduce need for more costly professional care.

Research on AA Group Attendance

“Studies to date generally show that only about 25 - 35% of those who attend one meeting of AA go on to active participation.” Tom McLellan, PhD

“Overall, studies suggest that between 55 and 80% of alcoholics encouraged to attend AA while in treatment will stop attending AA within 9 months.”

Scott Tonigan, PhD

What’s AA’s Drop-Out Rate?

What about 12-step facilitation?

“No single treatment is appropriate for everyone.” NIDA’s Principles of Drug Abuse Treatment

“We have the right – as do our families and friends – to know about the many pathways to recovery.” Recovery Bill of Rights, Faces and Voices of Recovery

“The research evidence clearly demonstrates that a one-size-fits-all approach to addiction treatment typically is a recipe for failure.” Addiction Medicine: Closing the Gap Between Science and Practice, CASA Columbia, 2012

• SMART Recovery (Self-Management and Recovery Training) – based on cognitive-behavioral principles and motivational interviewing

• Women for Sobriety – employs 13 statements emphasizing self-worth, emotional/spiritual growth, not dwelling on the past, personal responsibility, problem solving

Non 12-Step Mutual Help Groups

• Secular Organizations for Sobriety (SOS)– views recovery as individual responsibility, separate from spirituality/uses cognitive approach

• LifeRing –uses group process (secular) to empower the “sober self” within each participant to work out own path to sobriety

• Moderation Management – uses CBT principles to cut back or quit drinking before

it becomes severe

Everyone with a substance use disorder needs treatment

KEY FINDING: One-size-fits-all approaches

Failure to use evidence-based practices

Overuse of ineffective approachesUnderuse of addiction medications

KEY FINDING: Gap between science & practice

Evidence-based practices

Cognitive-Behavioral Therapy 12-Step Facilitation Motivational Interviewing Contingency Management Behavioral Couples Therapy (Family

therapy for teens) CRA (Community Reinforcement) CRAFT for families

“Perhaps the most alarming finding was that what the researchers termed ‘chat’ occurred much more frequently than science-based interventions. Often, the counselors revealed personal things irrelevant to the client’s issues.”

Kathleen Carroll, Ph.D.,et al, Yale


“There was a lot of checking in with clients to see how they were doing, very little content in the areas of relapse prevention and CBT, and a lot of winging it…”

Adam Brooks, Ph.D., TRI


CRAFT – Community Reinforcement& Family Training

Produced 3X more pt engagement than Al-Anon/Nar-Anon and 2X that of Johnson intervention

Overall, CRAFT encouraged ~ 2/3 of treatment-resistant patients to attend treatment

Roozen, et al (Review) Addiction, 2010)

Overuse of ineffective approaches


LECTURES and VIDEOS –“After we all checked in, they typically showed a video of something and talked about it. We spent too much time replaying videos on how your brain works.” Sadie A.

Overuse of ineffective approaches


DWELLING ON THE PAST: “The message was that you were born a drunk and will always be one. Look at your life and the consequences of your actions. Very little time was spent on creating a future once you cleared an area in your life.” Eddie F.

Underuse of addiction medications


Approximately 2 out of 10 facilities reported using one of FDA-approved medications for treating alcohol problems (N-SSATS)

• naltrexone • disulfiram • acamprosate

Underuse of addiction medications


“Fewer than 10 percent of all people dependent on opioids in the United States are receiving substitution treatment... The continued use of methadone and buprenorphine to detoxify patients from opioids is the most damaging aspect of current treatment of opioid dependence.” Health Affairs 32, no. 8, 2013

“A miracle drug”

“In the past, I always wanted to use—it always consumedme before. This is the one thing that Suboxone has taken awayfrom me. Now, I can sit and read a book.” Curtis M.

AccreditationCredentialing

KEY FINDING: What should protect us doesn’t

Accreditation

In facilities subject to state regulation, staffing requirements do not consistently mandate involvement of professionals capable of providing a full range of effective interventions... “For no other health condition are such exemptions from routine governmental oversight considered acceptable practice.”

CASA Columbia, 2012

“In few other fields do we place some of the most difficult and complicated patients in the health-care system with some of the least-trained folks among us. ”

Credentialing

Principles for a State-of-the-Art RehabJeffrey Foote, PhD, Ctr for Motivation and Change, NY

PRINCIPLE #1: Hire highly qualified staff, pay them what their qualifications deserve, and keep them happy doing the very hard work they do

PRINCIPLE #2: Keep track of how you’re doing and have it be a transparent, nonthreatening support system

PRINCIPLE #3: Make EBTs the foundation of your program, but give clients a choice in the matter


PRINCIPLE #4: Train, supervise, and retrain staff in EBTs (a huge job)

PRINCIPLE # 5: Hire therapists who can demonstrate empathy and run an organization that backs up this value

PRINCIPLE #6: Work with families—and not just “our family worker will do some psychoeducation with you”


PRINCIPLE #7: One size doesn’t fi t all

PRINCIPLE # 8: Address trauma... It’s not all about drugs.

PRINCIPLE #9: Embed treatment in life, understand substance use in the context of a person’s life, and recognize the importance of helping clients develop a full life to compete with the pull of their substance use

inside rehab: findings from an author’s four-year exploration of the u.s. addiction treatment...

Documents