Who Needs Rehab?

CAVANAUGH: This is KPBS Midday Edition. I'm Maureen Cavanaugh. In today's America, we've developed a ritual around the treatment of substance abuse. First, a problem is suspected. Then addictive behavior becomes evident. Then authorities step in, either in the step of parent, law enforcement, or through an intervention of concerned friends. Of and the only place to go next is rehab. From celebrities to high school drinkers, it's widely accepted as the best way for addicts to get clean. But is it really the best way? My guest, Ann Fletcher has examined the facts and fallacies in drug and rehab programs in a new book called inside rehab. The surprising truth about addiction treatment. FLETCHER: Good to be with you. CAVANAUGH: What does going into rehab actually mean? Is it only entering an in-patient facility? FLETCHER: Well, most people think of it as residential treatment, where you go away for -- well, the stereotype was 28-30 days. Most people recognize that's not enough now. But a lot of reinsurance companies won't reimburse for more than a few weeks. A lot of people in the field are recognizing this is a chronic disorder like diabetes, like heart disease that is something that people go in and out of remission from for their entire lives. But there are people who are in long-term recovery. But anyway, residential rehab is really what is needed by the minority of people with substance drug and alcohol problems. That's where you go for -- into treatment, you stay at a place, and you live there basically for a period of time. Most of treatment in this country, 80-90% of it is outpatient treatment, where you go usually for a couple of hour, several times a week. That's usually what most people do, and it actually has been shown in research studies to be equally effective to residential treatment. So this knee jerk reaction that everybody has to go to rehab is really a myth. CAVANAUGH: Now, you visited 15 different facilities. Did you find a lot of differences between the centers? FLETCHER: Huge, huge differences. I went coast to coast from Philadelphia to right here in La Jolla, a place called Practical can have recovery. And I live in Minnesota, we often joke it's the land of 10,000 treatment centers in Minnesota. And I looked at everything from programs -- outpatient programs that treat indigent people to high-end fancy 12-step programs, that you typically see on TV, and that's what most treatment is in the United States. But I also visited some evidence-based treatment, that is more cutting edge. And I also interviewed more than 100 people who recently been through rehab. And which I say rehab, I'm talking about all kinds of treatment, outpatient and residential. It's rehabilitation from a drug or alcohol problem. CAVANAUGH: Did you find any similarities? Your book has the title "inside rehab." It inspires me to ask what does go on inside rehab? Is it all very different? Or are there some votereds? FLETCHER: I did, unfortunately. And that's kind of the bad news. I got really intrigued. This book was almost a five year process. My first book was sober for good, which came out in 2001. And that was really about the common threads against people who had long-term recovery from serious drinking problems, or alcoholism is the colloquial term. Experts call it alcohol-dependence. About five years ago, really celebrity rehab became a hot-button issue with Lindsey and Brittany, that's when I really got interested. And I had gotten to know an expert in the field who really studies addiction treatment programs, doctor Thomas McClellan in Philadelphia. He kept telling me about the terrible state of addiction treatment in this country, which is not something I wrote about in the first book. And I stayed friendly with him over the years, and as I was looking into the celebrities going in and out, and talking to the doctor, and he would tell me things like the turnover in treatment programs is as high as that in fast food restaurants. CAVANAUGH: You mean people who work as counselors? FLETCHER: Yeah! The staff doesn't stick around! Well, that's not good for patients. People are not happy in their work, they're not paid well, they come and go quickly, there's lack of continuity. Very few programs he was finding, and he was studying these in a systematic way. He was not finding that these programs had doctors, nurses, psychologists, the kinds of people you would think would be providing care for addiction. It's one of the most complex disorders there is. More than half of people who have a substance use disorder, a serious drug or alcohol problem, also have an accompanying psychological problem, depression, anxiety. And he was not finding that these problems were being addressed. And I would say Tom! You need to write a book. And he was busy doing his research, and I finally decided I was going to go inside. CAVANAUGH: When you talk about the lack of highly qualified people conducting these rehabilitation, are you talking about higher end facilities or the lower end? FLETCHER: Across the board. When you were asking me about the common threads, some of the common things I found, it wasn't just me. I also interviewed many experts, looked at much research in the field. Right before I was finishing the book, a huge report came out from a think tank organization in New York, and they were doing the same thing I was doing at the same time. They were studying the state of addiction treatment in the country, and they released a huge report. You can go to their website, it's it CASA, and it's a huge indictment of our treatment industry. They looked at the qualifications are in becoming a counselor, that's who provides the bulk of treatment. And in more than half the states, you do not have to have a bachelor's degree to be a could counselor. In the programs that I visited, I did not have to have a bachelor's degree. What I found was that at some of the high-end programs where you're paying about $30,000 a month, most of the care was provided by a bachelor's level, sometimes a masters level. CAVANAUGH: And that's important because as you said, the addiction -- treating it is so complicated, right? FLETCHER: Exactly. And the training. Learning to look at psyche logical studies, the supervision you get when you have masters degree training. I used to work clinically in nutrition years ago. But the advanced training that you get for a complex problem like obesity or addiction is so important. CAVANAUGH: I wanted to ask about the price involved. It really cell out of bounds for most people, isn't it? FLETCHER: Some of these high-end places get insurance reimbursement for a lot of people. They have contracts with insurance companies. And a lot of them will help you. You pay out of pocket, and your insurance company may or may not pay for part of it. One of the really interesting things is that there's not a do relation between what you pay and the quality of treatment. Sometimes it is. But people make that assumption that the more you pay the better the treatment. I found some very high-quality programs that were community-based outpatient programs. One of the reasons for that is that they're off funded by government grants. Grants require that you use science-based treatment, masters degree level counselors. So very low-income people getting comprehensive care where they they were treating the whole person, not just the addiction. Sending them back to school, working with them on parenting, helping them find jobs. That's what you really need to help a punish with a seer addiction. CAVANAUGH: And that grant, become $32,000 for a 30-day inpatient treatment like Betty Ford. If your not reimbursed, that's really out of sight. FLETCHER: It's a huge amount of money. CAVANAUGH: Let's talk more about this science-based approach. This is different from what we've heard a lot about when it comes to 12-step programs. ; is that right? FLETCHER: Well, a 12-step program may or may not be science-based. The 12 steps -- one of the things I found was a common thread is that treatment in this country tends to be one size fits all. And that's a problem. Most of the programs in this country are based on group counseling. If you're in depression, we don't use a group counseling approach. This is a psychological addiction. To think about everybody with an addiction belongs in a group program where we sit around -- some of these high-end programs have eight hours of group work a day where you're sitting in group lectures, counseling. Many people I interviewed said I wasn't able to get sober. I interviewed people who went to rehab, 10, 20 times! They had the same kind of treatment over and over again! If you have heart disease and the first approach doesn't work, they don't keep sending you back to the same thing over and over again. Groups don't work for a lot of people. And a lot of these high-end people, in group eight hours a day, only individual counseling 3-5 hours a week. If you have a cooccurring psychological program, you might get a short visit with a psychiatrist one hour a week with a psychologist. Some of your really high-end program, with the traditional Minnesota model, I did visit some programs that had a completely different model where there was individual care. But in is the typical program, you would get if you had a diagnosis bike depression, you might get one hour a a week with a psychologist. 50's paying $30,000 for treatment, I would see a psychologist much more than that. CAVANAUGH: So would it be your advice then, what people should do, how they can get the best care to, look for one of these evidence-based programs? FLETCHER: Yeah, I have lots of questions to ask, here are the things you should ask, look for, what percentage of time will be spent in individual counselling, what are the qualifications? Don't assume that you have to go to rehab. I would never start there unless you have a horrible serious addiction. And even then it might not be necessary. There are many individual therapists. I live in a rural up to, there are some excellent mental health professionals that are trained in addictions. There are a lot of shortcomings in our general mental health and medical system that people are not trained. But I tell how you find a psychologist, a psychiatrist, a social worker who has training in addictions, in my small city I can think of a number of people who have training. You go for a one-on-one assessment. They work with you individually. They would not have a vested interest in admitting you into their program. If you go to a program for an assessment, they're going to admit you. You may or may not need to have that treatment. You would ask me about the 12 steps. They're freight when they work. We know that people tend to do better if they join the -- or there's an association. We don't know that it's cause and effect. But people who tend to join a 12-step group like AA get involved, find a sponsor Gto meetings regularly, tend to do better over the long-term. The problem is, most people don't stick with it. Of up to 8-10 people will drop out within a year. That's the problem. And they're never told about alternatives. There's smart recovery. Women for sobriety. Secular organizations for sobriety. There's a large number of smart recovery groups in this area. If you go to a rehab, I ask them do you tell people about alternatives? They do not. Most of them do not. CAVANAUGH: It occurs to me, have you gotten any pushback on this information? FLETCHER: I really thought they would am and I haven't! Some of the programs have reached out to me. It's been a mind-blower! One of the very powerful traditional programs has reached out and said it's time that we joined hands. There's enough addicts to go around for everybody! And I think it really is very positive. The world is ready for change. I've seen changes in some of the places I visited since I went there. CAVANAUGH: The book is called inside rehab, the surprising truth about addiction treatment and how to get help that works. Thank you so much FLETCHER: Thank you.