Over the past 30 years I have worked in and created nearly a dozen addiction, co-occurring disorder, and mental health hospitals, intensive outpatient programs, and residential treatment centers around the US and overseas. And guess what? Over the years I’ve seen a lot of things that bother me. Here’s a quick sample of what’s gone wrong over the last few decades in addiction healthcare. (And I’m sure that many of you have your own thoughts to add.)
- Extraordinary treatment programs have thrived, prospered and provided amazing care, only to be killed off by corporate greed.
- Programs have been closed by the government due to poor client care and/or insurance fraud.
- Marketing campaigns have masked the realities of expensive, poorly run programs.
- Unique and effective mom and pop treatment organizations, bought up by corporate entities, have homogenized and relaunched into look-a-likes, losing the dignity and spirit that made them special.
- Facilities have sold yoga, equine therapy, massage, and meditation as “required for good addiction treatment” when the fact is those are luxury extras rather than primary work.
- Programs lack clinical leadership or structure, with therapists (often part-time) doing whatever they feel is best without direction or an overall vision.
- Bachelor’s level clinicians are asked to perform master’s and PhD level work.
- Senior staff debates about whether to challenge wealthy clients on their clearly problematic acting out (rage, entitlement, etc. Often, they are forced to call the corporate office before such a confrontation because they are so fearful that a $60K client will get upset and leave treatment.
- An almost universal failure to provide adequate adjunct mental health resources.
To all this, I say enough. We can do better.
All of this has been a primary part of my thinking process for the last several months as I seek to create and grow new treatment programs in an old-fashioned way—with good people who know and are deeply dedicated to their craft. For me, this is mostly about going back to the basics (the stuff that has steadily gone by the wayside in this era of corporate-run mega-treatment). So, as I work double-time to create new treatment centers across the globe, I’ve created a ten-item list of necessities for creating the best possible programming.
- Accurate Assessment: If someone comes to your facility for treatment, you need to fully and accurately assess that individual to make sure he or she is actually dealing with the issue you treat. Moreover, you need to make sure the symptoms that person is showing are not caused by some other underlying issue. For instance, individuals with bipolar disorder may act out sexually during the manic phase, and they may (because they become obsessed with and compulsive with sex, leading to negative life consequences) believe they are sexually addicted. However, if they only act out sexually during the manic phase of bipolar disorder, their sexual issue is not addiction but a (temporary) manifestation of their bipolar disorder. If I run a sex addiction facility and opt to keep this person in treatment, I am doing this client a disservice. With proper assessment, individuals who don’t belong in a particular treatment center can be referred to a better option. They’ll get the treatment they need, and other clients at the center won’t be distracted by a person who doesn’t belong.
- Hire the Right Professionals: It is important to hire experienced master’s and PhD level professionals as a significant part of the treatment team. These are the individuals best-qualified to perform accurate assessments, to explore co-occurring disorders, to uncover trauma (using that knowledge to inform addiction work), etc. Without the right staff, you can’t do the right work. It’s not the location or the building or the marking department that makes an addiction rehab successful, it’s the work that’s done in treatment. Hire the best and you’ll do the best possible work. And make sure you value your staff, letting them know they are wanted and appreciated. Treat them like gold. That way they’ll stick around and you’ll avoid unnecessary (and disruptive) turnover.
- Acknowledge Trauma: All meaningful addiction treatment should be trauma-informed. That said, providing actual trauma treatment in the early stages of recovery is generally contraindicated, as we’re dealing with individuals who are already highly dysregulated. They are simply not yet stable enough to do in-depth trauma work. Nevertheless, clients will benefit from knowing about the trauma they’ve experienced. At the very least, this knowledge can reduce shame about both the trauma and the addiction. Once the addict has established sobriety and rebuilt his or her ego-strength, actual trauma work can be undertaken. Usually, this is post-rehab.
- Treat the Whole Person: Treating addicts holistically is imperative in good addiction treatment. We must teach them about everything that affects their addiction, including mental, emotional, and environmental concerns. Otherwise, they will never fully understand their weaknesses and how to overcome them. This is where mental health, spiritual health, and physical health cross with the additions. Rather than focusing solely on addiction, we should also teach clients about depression, anxiety, OCD, exercise, diet, and any other issues that may play into addiction.
- Create Opportunities for Social Learning: Effective treatment means doing more than treating the individual, it means teaching clients how to use and depend upon a community of immediate and longer-term support. At its best, treatment is a life-altering experience of bonding, learning to trust, becoming accountable, and developing integrity. For this, social learning is needed, making the group the center of the program, not the individual. Thus, we must teach and model healthy connection, always inviting our clients to become more trusting and emotionally bonded.
- Treat the Mind as Well as the Heart: In addiction treatment, we absolutely must attend to feelings, emotional reactivity, post-traumatic stress, and the like. But it’s not OK to run a treatment center where all that clients do is feel. Yes, opening up feelings, working through feelings, sharing feelings, and helping addicts learn about and understand their emotional states and how to effectively handle them is one needed part of treatment. But it is not the whole enchilada. Clients also need to exercise their minds. As such, psychoeducation is a key component of effective addiction treatment. At the very least, clients should understand what addiction is, what it looks like, and how it manifests in their life. They should be able to identify their triggers, recognize their denial, and understand their addictive cycle (including when/how they can best intervene). Without this knowledge, all the feelings work in the world won’t keep them sober.
- Individualized Treatment Plans for Every Client: Sure, every treatment center says they do this. But in my experience, they’re usually not doing this for the client’s benefit; they’re doing it because insurance companies require it. This is the wrong approach. Addiction treatment requires individual treatment plans because every addict is different, with a unique history and background and set of life goals. Instead of ignoring this fact and treating every addict with a one-size-fits-all program, we need to assess and examine each client in-depth and tailor the programming to his or her needs. Even group work can be modified based on client needs. If I give a lecture one way this month and it goes over really well, that doesn’t mean I won’t need to alter it next month based on client needs.
- Include Family, Especially Spouses/Partners: Addiction is often referred to as an intimacy disorder because addicts would rather turn to a substance or behavior than a person for emotional regulation and support. A significant part of long-term recovery from addiction is learning to connect with and rely on loved ones. Thus, family must be integrally included, when possible, in addiction treatment. But not by using the blaming, shaming codependency model. It is far better to use the much more welcoming prodependence model, which engages loved ones and teaches them to help effectively, rather than pushing them away.
- Sell Treatment, Not Vacations: Addiction treatment centers that do a great job will develop a great reputation with therapists and recovering addicts. And that’s what fills a program. Pretty pictures on a website and the promise of a spa-like setting are good selling points, but if you’re not providing effective treatment, then word of that shortcoming will spread. Treatment-first treatment centers are busy treatment centers. Period. I can run an amazing and unforgettable treatment program with eight clients and a whiteboard. Yoga, massage, mindfulness, adventure therapy, and the like can be useful, but they are not primary addiction treatment. Primary addiction treatment is hard work; the rest is optional. So let’s stop selling treatment as a vacation and start selling it as the difficult but life-altering experience it can (and should) be.
- Accept the Need to Specialize: Effective addiction treatment is about doing the best possible work in your area of expertise. Addiction treatment centers need to do what they do and do it extremely well. If a facility has a specialty (and it absolutely should), it needs to stick to it. How many treatment centers out there promise to treat every form of addiction? Most of them, that’s how many. But trust me, there’s a big difference between chemical dependency and issues like video game addiction, sex addiction, gambling addiction, and eating disorders. And t=running a topic-specific group once a week does not make that topic an area of specialization. What it does do is water down a facility’s true focus.
At the end of the day, great clinical work arises out of ethical people doing solid work because they understand and care about the people they’re treating. Great work never arises out of higher margins or volume. If we focus on the treatment work, the bottom line will take care of itself. More importantly, our clients will heal.