The Rehab Industry Needs to Clean Up Its Act. Here's How.

Feb 04 2016

The Rehab Industry Needs to Clean Up Its Act. Here’s How.

No one argues that the American addiction treatment system is anywhere near optimal—even its cheerleaders recognize that there’s miles to go before all people with addiction have access to respectful, ethical, effective and evidence-based care. Worse, the past year has seen myriad media exposes and financial, sexual and maltreatment scandals.

Of course, done right, addiction treatment can transform lives, with a hugely positive impact on society. It is often the difference between life and death, or between a productive recovery and a life of despair. Yet all too often that opportunity is being blown.

So what is the best way forward? And what are the biggest steps the industry itself can take to improve?

“What we simply need is a nice bulldozer, so that we could level the entire industry and start from scratch,” says Dr. Mark Willenbring, former director of treatment and recovery research at the National Institute on Alcohol Abuse and Alcoholism and the founder of Alltyr, a center in St. Paul, Minnesota offering evidence-based alternatives to the mainstream model. “Another approach is that you could use dynamite,” he deadpans.

But he’s serious about the need for radical change. “There’s no such thing as an evidence-based rehab,” he says. “That’s because no matter what you do, the whole concept of rehab is flawed and unsupported by evidence.”

Unsurprisingly, Marvin Ventrell, executive director of the National Association of Addiction Treatment Providers (NAATP), an organization that has represented rehabs like Hazelden and the Betty Ford Center (now merged) since 1978, doesn’t see the need for such an extreme makeover.

However, even he says that the industry is at a “crossroads,” and “we have bad actors out there.”  He adds, “If our procedures for self-policing and transparency aren’t improved, the industry is going to be seriously harmed.”

I have covered addiction as a journalist for nearly three decades, and also have my own history of heroin and cocaine addiction, and of receiving treatment. With the input of longtime leaders in and critics of the field, here are my views on what needs to change.

1. Remove 12-step-related content from treatment—or at least, stop charging for it

In no other mainstream medical or psychological specialty are patients told that the best treatment for their disease is surrender to a higher power, confession and prayer—and, often, that if they don’t accept this method, the only alternative is “jails, institutions or death.”

And in no other area of medicine do insurers pay for hours of group “therapy,” films and lectures that consist overwhelmingly of indoctrination into the teachings of a self-help group, available for free in church basements. As I see it, this is not only a violation of the Eighth Tradition of Alcoholics Anonymous—which says that members should not be paid for their “usual 12th-step work” of helping other alcoholics and addicts get the program—but also a tremendous waste of scarce resources.

Ventrell disagrees, saying that “psychosocial care is not severable from 12-step care” and that 12-step rehabs like Hazelden provide a good model for treatment. But Willenbring argues, “We used to treat breast cancer with prayer, too. We don’t that do anymore.” He favors keeping 12-step programs and treatment separate.

We’re far from that, however. Currently, at least 80% of American inpatient and outpatient drug-free rehab is dominated by the goal of getting patients to accept the ideology of 12-step programs and to attend as aftercare. To my mind, while 12-step programs do help some people, there is absolutely no reason that taxpayers or insurers should pay for the exact same social support and information that can be had for nothing at meetings.

Instead, treatment providers need to cull from their programs the elements that are redundant with 12-step groups—and instead offer evidence-based therapies like cognitive behavioral therapy and motivational enhancement therapy. Patients don’t have the option of getting these for free outside of formal treatment—and the role of treatment should be provide professional medical and psychological care, not self-help.

Removing 12-step ideology from treatment will also allow for easier integration of medication and whatever new approaches research shows over time to be helpful.

2. Ensure access to maintenance treatment for opioid addiction

In any other area of medicine, if patients were not informed about a treatment that cuts mortality by at least half—while being given one that has no effect on it—it would be considered malpractice. And if there were a federal law that limited access to such treatment and said that doctors could only treat a limited number of patients… Well, there probably wouldn’t be one.

But in the addictions field—largely because the dominant abstinence-only model historically hasn’t recognized medication-assisted treatment (MAT) as an acceptable form of recovery—this happens almost every time someone with an opioid addiction enters an abstinence-only 28-day rehab, a detox or an abstinence-based outpatient program. As National Institute of Drug Abuse director Nora Volkow put it in testimony to Congress last year, for opioids, “treatment programs with an abstinence focus generally do not facilitate patients’ long-term, stable recovery.”

Research shows that people who stay on methadone or buprenorphine long term have half the death rate of those who detox from these medications or participate in abstinence-only treatment. (There is no similar data for antagonist medications, including Vivitrol).

Given this, stigmatizing maintenance or telling patients that it is “not really recovery,” is basically killing people. As is the federal cap on the number of buprenorphine patients doctors may treat for addiction in their practice, which was imposed when the FDA approved the drug for addiction and limits most doctors to 100 patients. Since some patients may stay in treatment for decades, the slots fill up fast.

Jeff Deeney, a social worker at a Philadelphia treatment program, is currently faced with the problem of the cap. “We’re dead stuck,” he says. “We have a line four blocks long on our waiting list. We’re maxed out. We’re trying to hire another doctor just to walk in and write scripts.”

President Obama should take executive action and end this arbitrary regulation immediately.

Thankfully, even many dedicated 12-step supporters have come to recognize the need for medication use. NAATP’s Ventrell says that “program integration,” is a critical part of improving addiction care, particularly “depolarizing” the clash between 12-step views and support for MAT. He states bluntly that if counselors or program management see it as being just another form of active addiction, “They’re not providing good care.”

Willenbring puts it even more strongly. “I think there needs to be a lawsuit against a prominent rehab for wrongful death and deprivation of informed consent and negligence,” he says, referring to cases where patients have overdosed immediately upon leaving and were not told that maintenance would reduce their mortality risk.

3.  Fight corruption and unethical practices

In the past year, the addiction treatment industry—never trouble-free in the best of times—has been wracked by scandal. A New York Times front-page exposé revealed sickening conditions, kickbacks and even forcing addicts to relapse to stay housed in supposed “3/4 houses” in the city. The Huffington Post (disclosure: I’m interviewed) published an in-depth investigation of how people with addiction in Kentucky are mistreated and denied access to MAT.

Buzzfeed investigated overdose deaths, kickbacks and overcharging for urine testing in Delray Beach, Florida “sober living” homes, which were also the subject of 2014 FBI and IRS investigations. The Los Angeles Times revealed that the owner of a network of LA rehabs was being investigated by the state and the FBI, for, among other things, sexual relationships with patients, poor care and fraud.

And that wasn’t all. Longtime industry leader and Beyoncé-favorite Phoenix House was also investigated by Reuters for a patient death, for running facilities led by abusive staff and filled with drug use, assault and sexual violence, and for financial mismanagement.

Clearly, change is needed. Even the industry group, NAATP, wants federal regulation to ban practices like “patient brokering,” in which rehabs and sober living homes pay kickbacks for referrals to each other, without regard for whether a facility or service is appropriate for that patient. While the practice is illegal in some states, it is not against the law on the federal level. As Ventrell says, “It should be.”

Another common ethics issue involves misuse of the internet, with some rogue programs actually hijacking web traffic from other sites and transferring phone calls to their own agents. “Some horrible abuses have gone on there,” Ventrell says, noting that the only thing his organization can currently do about it is expel members if they are found to engage in such practices.

4. End the reliance on criminal justice system referrals

The great harm reductionist Alan Marlatt (RIP) frequently used an analogy that compared the rehab industry to other customer-focused businesses. A car company, he noted, faced with declining sales and lack of consumer interest, would not complain that customers are “in denial” about the quality of their vehicles. Nor would it try to have the government arrest people who refused to buy their cars. Instead, they’d improve their offerings—or, at the very least, their marketing and consumer outreach.

But the treatment industry has for too long relied on referrals from the criminal justice system to stay solvent. Because at least one-third of treatment slots—and in many programs up to 80%—are occupied by people whose only other alternative is prison, the industry has had little incentive to make itself warm and welcoming. Instead, it has frequently counseled relatives to practice “tough love” and stage “interventions,” where if the addicted person doesn’t immediately go to rehab, he will lose friends, family and possibly employment.

Several problems result. For one, since their biggest customer is often the criminal justice system, many programs shape themselves to its dictates. “The field has been so distorted by its dependence on the criminal justice system, which is really the client,” Willenbring says, contrasting it to other forms of medical care which have to work to attract patients. Since the criminal justice system is supposed to punish offenders, this leads to support for controlling, punitive and shaming practices in treatment, which are counterproductive.

This is problematic not only for people mandated to treatment, but for everyone else.  Because research shows that empathy and rapport between clients and counselors is the best predictor of positive outcomes, a treatment center that is cold and punitive will be less effective on that basis alone.

Secondly, if a large proportion of the people in a treatment center have been forced to be there and only grudgingly participate, this can interfere with its ability to create a “safe space” for others. It’s hard to open up and be vulnerable while sharing deeply personal experiences of trauma when other patients are laughing or staring stonily at the clock.

One way around this is for programs not to accept coerced patients who haven’t been provided a menu of treatment options—a policy that would also improve drug court outcomes by better matching patients to treatment they prefer. This way, too, providers would have to compete for customers and the criminal justice system’s influence would be reduced. (Even better, of course, would be to decriminalize drugs, but that’s another column.)

5.  End humiliation and confrontation

It’s been known for decades—as I showed in-depth in my 2006 book, Help At Any Cost: How The Troubled-Teen Industry Cons Parents and Hurts Kids—that confrontational and humiliating “attack therapies” are ineffective and often harmful.

Unfortunately, nearly all long-term residential treatment centers in America— i.e., “therapeutic community” programs that last three months or longer—were originally modeled on a destructive cult called Synanon. Most famous for placing a poisonous snake in the mailbox of an attorney who opposed it, Synanon was founded by an AA member who believed that the steps needed to be applied by force and that people with addiction needed to be broken down completely before they could recover.

Phoenix House, Daytop and Delancey Street were all directly modeled on Synanon—and any program that uses “marathon” therapy groups, “pull ups” (confrontations), makes patients wear degrading signs or outfits and has a hierarchy of positions through which patients rise towards graduation has its roots in Synanon, either directly or indirectly, through staff training. And unfortunately, these methods are also favored by some staff at 28-day rehab programs or intensive outpatient treatments.

While many have moved away from the most extreme tactics, a widespread belief that all people with addiction are lying “whenever their lips are moving” and a sense that negative experience is necessary to get people to realize that they need to change remains common. This is a barrier to successful treatment, because, as William White and William Miller show in this devastating 2007 paper, no study has ever found this approach to be better than kinder alternatives. More confrontation tends to lead to more drinking and drug use, not less.

If we want better treatment, the industry must treat clients with respect and dignity, and stop taking an attitude that the rest of medicine abandoned as harmful decades ago.

6. De-emphasize residential treatment

Research has long shown that in most cases, outpatient treatment is as effective as inpatient care for alcoholism and other addictions. Moreover, as noted earlier, when the substance involved is opioids, outpatient maintenance with methadone or buprenorphine cuts the death rate by at least half compared to residential or outpatient abstinence treatment.

Many people believe that since celebrities go to exclusive spa-like rehabs, this is the most effective type of addiction care. But the data doesn’t support this. “Staying overnight together confers no outcomes advantage,” Willenbring says, adding that research on learning shows that people do not transfer skills acquired in an isolated setting back to their daily lives where they are most needed.

“You cannot learn recovery skills in rehab,” he says. “The work doesn’t start till you get home.” Given that—and the expense of inpatient treatment—it makes sense to limit inpatient care to the shortest possible period necessary for medical stabilization. People also do better at recovering from all types of illness when they are surrounded by their loved ones and can sleep in their own beds.

Of course, for people who live with drug dealers and are in a social setting in which they have no friends or relatives who aren’t also drug buddies, a change of locale could well be beneficial. But that doesn’t mean that living in a treatment program that costs thousands of dollars a day for a month or longer is the best way to accomplish this.

7. Create truly independent accrediting bodies that are consumer-friendly—and national standards of care

Since I write regularly about abusive treatment programs—I’m talking places where beating, sleep-depriving, sexually humiliating and starving patients are seen as acceptable—I’ve had some experience with patients who have legitimate complaints. This is where program accreditors like the Joint Commission and CARF are supposed to come in. Being accredited by at least one of these organizations is supposed to be a sign that the program provides high quality treatment and treats patients with dignity and respect.

Unfortunately, one of the most abusive programs I ever wrote about—Straight Incorporated— was accredited by the Joint Commission at several of its sites. And as late as 2007, a copycat program was accredited by CARF.

At that time, it was extremely difficult for patients to navigate their websites even to figure out how to make a complaint—I’m happy to say that at least in terms of accessibility, that has changed and both groups now have easily located complaint forms. Still, even now, at least one program that was the subject of a major media expose involving serious patient safety and maltreatment problems last year remains accredited.

Further, in order to complain, consumers need to know which of these groups has accredited the program—and the accreditation process is still paid for and guided by the programs. Basically, this means that rehabs know in advance when they will be inspected for accreditation and that accreditors are financially dependent on the programs they are evaluating.

To me, this is a real conflict of interest. Given the fact that state treatment regulation is often lax and there are no federal standards even for basic things like counselor education, accreditation may be the only serious oversight some programs get. We need to make accreditors independent (or at least, less dependent) and ensure that consumer complaints about unsafe or harmful practices are easy to make and are taken seriously.

We also need national standards for counselor education, for best practices in all types of treatment and for informed consent regarding options like medication. All counselors need to be educated about all aspects of addiction, not just their own recovery—and especially, about mental illness and what they are and are not equipped to treat without medical supervision.  We should create scholarships to ensure that people in recovery can get the education they need to qualify and create staff positions that allow for various levels of education—but we should not have lower standards for addiction care than for other specialties.

8. Expand harm reduction

It’s completely outrageous that it took 27 years for the federal government to finally end its ban on funding needle exchange programs, which happened last December. Even when the ban was first passed in 1988,  it was already clear from European data that the programs worked. It took an HIV outbreak in Indiana that infected 175 people last year to finally wake recalcitrant Republicans up.

But expanding needle exchange to where it is needed across the country is not enough. We also need to start providing safe injection facilities (like this one in Canada, which cut local overdose rates by 35%) make naloxone as accessible as possible (including to opioid-addicted people leaving abstinence programs and incarceration) and integrate harm reduction ideas into the treatment system so that people who are not ready for abstinence have options other than simply continuing without medical care.

Of course, none of these eight changes are easy to make, and there are substantial institutional and ideological barriers to many of them.

But even just one—done thoroughly—could have an enormous impact on the quality of addiction care in America. And if all of them were made, the system would be transformed—with or without a bulldozer.

Maia Szalavitz is a columnist for The Influence. She has written for Time, The New York Times, Scientific American Mind, the Washington Post and many other publications. She has also authored six books, including Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids (Riverhead, 2006). Her latest book is Unbroken Brain: a Revolutionary New Way of Understanding Addiction. You can follow her on Twitter: @maiasz

  • A New Freedom

    Unfortunately the problem lies within how we think treatment should work. You cannot change anything using the same thinking that created the problem. Your article fails to bring any new ideas that would benefit how we treat addiction. We shall allow you the same excuse as those before you. Addiction is without doubt the most elusive force science has been involved with. Because it is a symbiotic relationship with humankind it has no barriers. Understand that relationship exists beyond the addict. Addiction does some of its best work with those that have never used alcohol or drugs.
    We have empirical evidence that supports long term sobriety since 1935. In this time span millions of hopeless alcoholics and addicts have lived and died sober. The scientific and medical community is unable to grasp these successes. We are not a secondary solution to the epidemic of addiction. I admit our ranks must bridge the ever widening gap that exists between providers and science. That would require a level of humility that does not exist today. We have been doing the business of sobriety for a very long time. Instead of contempt, perhaps it would be wise to investigate. You see the addiction epidemic continues to rage through our lives leaving none of us unaffected.


    • Josh Craigle

      Um… I think all 8 steps bring new ideas to the table that would benefit how we treat addiction.

    • disqus_Quri44IJyq

      Although it’s not a new idea, the author makes a cogent article for why we must divorce AA and other 12-step groups from treatment. The current paradigm is a clear failure, but self-help and folk wisdom are much more profitable than actually hiring professionals to help people with addiction. We need to hold the addiction treatment industry accountable for their greed and suppression of evidence-based therapy.

    • Horatio Socks

      I used to be dead against AA. Today, I have a bit of a different opinion of it. Seems to me that most people I know, do not like the ‘God’ portion of AA. Not saying the author does or doesn’t, but that’s just what I’ve found to be true.

      My run-in’s have been with plenty of people (myself included) who have come to grips with the below 12 steps. Maybe not in the exact order they are written, but certainly in it’s entirety. As much as we all think we DO have control, we have very little control. We can’t control our kids, never mind other adults, and our own internal issues.

      And, internal issues are where the brunt of the problems with drugs and alcohol come in. External issues obviously come into play, but it’s how we deal with them.

      1. We admitted we were powerless over alcohol … that our lives had become

      2.Came to believe that a Power greater than ourselves could restore us to sanity.

      3.Made a decision to turn our will and our lives over to the care of GOD as we understood Him.”

      4.Made a searching and fearless moral inventory of ourselves.

      5.Admitted to GOD, to ourselves and to another human being the exact nature of our wrongs.

      6. Were entirely ready to have GOD remove all these defects of character.

      7.Humbly asked Him to remove all our shortcomings.

      8. Made a list of all persons we had harmed and became willing to make amends to them all.

      9.Made direct amends to such people wherever possible, except when to do so would injure them or others.

      10.Continued to take personal inventory and when we were wrong, promptly admitted it.

      11.Sought through prayer and meditation to improve our conscious contact with GOD as we understood Him, praying only for knowledge of His will, and the power to carry that out.

      12.Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and practice these principles in all our affairs.

    • disqus_Quri44IJyq

      Your empirical evidence is flawed.The initial physician study, for example, was rejected originally from the BMJ and only later, under pressure, was published. Subjects were not consented and further, no diagnostic criteria for “addiction” was set -then this “study” – performed by two people who benefit financially from the industry – was referenced in a large number of articles by “friends of” or “like-minded docs.” I challenge you to come up with one piece of evidence that states 12 step “spiritual” and poorly defined “treatment” has a higher success rate than medication assisted treatment – they don’t exist. AA has not published outcome studies. Treatment centers do not follow outcomes in most cases. It doesn’t work – we have over 14,000 drug and alcohol “treatment” centers in the US and our addiction problems are worse than ever.

  • techcafe

    ever hear of the Rat Park experiment? google it.

  • Chester Dickerson

    I’ve had my share of recovery centers. Recently, one seemed more concerned with greed, placing less emphasis on patient care. Too many people in the wrong positions, some not qualified nor practicing with in their scope of practice, while others take on group meetings without any education beyond high school and no credentials. We should have more stringent policing of these so-called recovery centers”. To see patients in recovery jacked up on meds not prescribed, to witness inappropriate behavior yet have such events transferred on to others, to see missing meds from the med room all being blamed on discharged patients, to be a part of what may be insurance faux is the utmost agregious of all. Keeping patients for 4 months instead of the max 3, and the list is never ending. How these centers survive without even a slap on the wrist is beyond me. Patients injured on sight should not be required to pay their own ER visit. Isn’t it the responsibility of the facility to do or cause no harm. Taking the word of a patient with regard to what may have been a fatal mistake, that all is ok is not responsible. Waiting to address issue the following day is even less responsible. Passing the buck and using others as scapegoats for their illegalities continues to be commonplace in detox/recovery centers. It’s a money making, patient raping business, unless it is well organized, has a common goal with credentialed staff members. The insurance companies need to keep close eyes on those facilities with high relapse rates. Something isn’t working. Get away from the 12 step program, do more insight research, nutrition has apparently taken back seat, and why do we allow those addicts smoking breaks. Smoking should never be allowed. It’s counterproductive. Why do we need to have candy jars full of candy. I was told because chocolate calms. Not a snickers bar or kit Kat. I believe that dark chocolate, high in cacao was the chocolate of reference.

    If laws are not stricter, if policing isn’t so minimal and inspections continue to be known in advance, how r we to uncover the band aid that the administration places on to masque the deeper injuries that need the most attention. It’s a game, at the expense of the innocent. The controllers are doing none of our community a favor by ripping off their patients. It’s sad, it’s unethical, and charges should be filed at both state and federal levels. We know that isn’t going to happen. The cover ups are way to creative. Wake up people. Scrutinize your options. Google the names of those involved. U may just be surprised by not having done your homework first.

    • disqus_Quri44IJyq

      I have provided some attorneys with cases and hope they wlll pursue some of these fraudulent claims and wrongful death suits.

  • iiOOOii

    #6 never actually occurred to me before even though in a cognitive science course we learned about how learning is context-based/not easily transferable (I can’t remember the contents of the particular study which I think is semi-canonical in contemporary psychology but it had something to do with underwater welding? or scuba diving? can’t really remember tbh). but i definitely have thought of “rehab” as like, some sort of definitive cure. very good article, thanks.

  • Ken g

    Great comprehensive article as usual-I look forward to your new book. As a part time addiction counselor and writer on the subject, you make a great and accurate case for the
    tremendous malfeasance in the re-hab world,and as a optimist by nature, I think we need a
    a think tank akin to the”Manhattan Project” to fix the ills of the recovery template.

    Unfortunately, if an addict is not ready,efficacy in the short term goes out the window. That does not mean he should be castigated and thrown to the street corner-we need to offer him harm-reduction as you say. You quote my hero,William Miller, who is not afraid to say “the best counselors are not necessarily the best educated but the most charimatic”. I have seen time and time again the later get fired,because the head counselor’s ego could not tolerate the better instincts of the less educated but more empathetic counselor.

    The only place I feel you are a tad mis-guided is in your overall negativity of AA. I agree !00%that profit centers like the Minnesota Model should find their own paradigm and not mimic AA-that is pathetic to me and always has been. And the fact that other TC’s use 12 step therapy in their advertising is egregious. However, as far as AA’s functionality as a free standalone rehab option it is a godsend to many. Forget that higher power assertion and AA is a place that is in fact communistic(The Transcendentalists view of the world) where a group conscious can be a very powerful thing. Furthermore, AA(you have to find the best meeting for yourself) has always offered kindness and a couch to sleep on and a meal-which is non-existent in any profit center rehab. My experience has always been that any collective put-down of AA is really just alcoholics projecting denial-AA is just free group therapy-you either like it or not but do not pounce on it.

    Finally,the Nora Volkow’s of the world have done some great neuro-science in this field(which I have studied and written about) but there is no one to follow through(big pharma is interested in AD,MS and other Neurological diseases)and Addiction Medicine
    for all intensive purposes unavailable for people with gov’t insurance and even regular insurance-they take cash…And it isn’t psychiatrist’s fault that they get reimbursed at’60’s
    DRG’s. Worst of all,is the 28 yr old

  • Ken g

    ( continuation of other comment)overworked Psychiatrists at the profit centers-they are forced to diagnose everybody with either BP1 or BP11 and prescribe them one of the atypical anti psychotics that make them heavy and diabetic in short order.

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  • disqus_Quri44IJyq

    Best article I’ve read on this in a while – I am reposting and sharing.

    • Dev_mom

      I’ve shared this article at least 3 times this ýear

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  • Hil O

    While the article has a lot of terrific insights, I believe there are a number of generalizations. One example is that most licensed or state approved programs that receive insurance or state funding for inpatient or outpatient treatment are required to use evidence-based programs. Another is the comment about the goal of 80% of programs being to connect their clients to 12 Step fellowships. What the statistics I saw really showed was that 83 % of 14,148 utilize 12 Step Facilitation Therapy. The stats did not say it was used with other ones. In fact, Substance Abuse Counseling, Relapse Prevention, CBT, Motivational Interviewing, and Brief Interventions were all rated as being used more than 12 Step Facilitation Counseling. With that said, counselors are supposed to practice counseling not AA or NA. Most of us do. The interesting thing is that alcohol counselor certification existed in some stated of the US before counselor licenses existed. The other concern I had about the article was the comment about Therapeutic Communties. Yes, they were modeled on Synanon back when they started but most have been significantly modified. I directed one once for 5 years. Only one staff person ever tried to treat someone they way they were treated in a concept TC. He never worked another shift in that program. I have worked in the field since 1977 and have never worked at a program “where where beating, sleep-depriving, sexually humiliating and starving patients are seen as acceptable.” If I had, you can be sure the police would have been called. The author has a lot of great ideas but it would be terrific if they had broader experience in what the majority of the field is an isn’t doing. This is not the 70’s.

    • That 80% statistic should be much lower because any facility that takes SAMHSA Funding should not be using religious methods like 12 Step Facilitation.

      Rules for SAMHSA/SABG Providers:

      § 54.3
      Nondiscrimination against religious organizations.

      (a) Religious organizations are eligible, on the same basis as any other organization, to participate in applicable programs, as long as their services are provided consistent with the Establishment Clause and the Free Exercise Clause of the First Amendment to the United States Constitution. Except as provided herein or in the SAMHSA Charitable Choice provisions, nothing in these regulations shall restrict the ability of the Federal government, or a State or local government, from applying to religious organizations the same eligibility conditions in applicable programs as are applied to any other nonprofit private organization.
      (b) Neither the Federal government nor a State or local government receiving funds under these programs shall discriminate against an organization that is, or applies to be, a program participant on the basis of religion or the organization’s religious character or affiliation.

      § 54.4
      Religious activities.
      No funds provided directly from SAMHSA or the relevant State or local government to organizations participating in applicable programs may be expended for inherently religious activities, such as worship, religious instruction, or proselytization. If an organization conducts such activities, it must offer them separately, in time or location, from the programs or services for which it receives funds directly from SAMHSA or the relevant State or local government under any applicable program, and participation must be voluntary for the program beneficiaries.

      § 54.5
      Religious character and independence.
      A religious organization that participates in an applicable program will retain its independence from Federal, State, and local governments and may continue to carry out its mission, including the definition, practice and expression of its religious beliefs. The organization may not expend funds that it receives directly from SAMHSA or the relevant State or local government to support any inherently religious activities, such as worship, religious instruction, or proselytization. Among other things, faith-based organizations may use space in their facilities to provide services supported by applicable programs, without removing religious art, icons, scriptures, or other symbols. In addition, a SAMHSA-funded religious organization retains the authority over its internal governance, and it may retain religious terms in its organization’s name, select its board members on a religious basis, and include religious references in its organization’s mission statements and other governing documents.

      • disqus_Quri44IJyq

        No American should be court mandated to a prayer group.

    • Yukon Cornileus

      Last winter Open Sky Wilderness Program in Colorado force marched six kids in bitter cold with light foot ware until their feet froze. Severe frost bite, they will have a life time of pain and suffering. This program has a history of abuse, violent strip searches, and starving teens in their “care” and they are suppose to be a “softer” program.
      Please open your eyes there is plenty of torture in America’s tough love treatment centers.

  • thederbycitygirl .

    Thank you for your insights after writing about recovery and also being involved in your own 12-Step Program of Recovery. I noticed from WIKI you do not have any kind of degree, either undergraduate or advanced and you “attended” Columbia University. I, therefore, cannot either agree nor disagree with your “findings” – I am a member of AA & NA for 24 years and was introduced to the 12 Step Program while in treatment long ago. It worked for me and I would recommend it to anyone suffering with this deadly disease. It is all about surrendering our self-will in order to begin to recover from our alcoholic and drug related consequences and our behaviors – while intoxicated or not. I have discovered the key to physical and emotional sobriety – all I have to do it use it….therein lies the problem with so many people who relapse and eventually fade into nothingness.

    • SaInRu

      Your post is passive aggressive and rude, which I would not expect less of someone who spent such a long time absorbing the 12-step “program”.

      It says a lot about a person’s intentions when they only look at Wikipedia for information about a subject, in this case, a person. That’s the behavior of someone unwilling to listen, or discuss a topic. Oddly enough, not listening or discussing an issue is the type of behavior people get shunned and ignoredfor in 12-step. I guess once you’re in the “program” it’s time to shut off all opposing views. Hence, your “I, therefore, cannot either agree nor disagree with your “findings”” statement is exactly what I’d expect. Congratulations, you sound just like an empty, self-righteous 12-step “elder”.

      And thank you for nailing down the problem of why others relapse. And what is that problem? They aren’t like youuuu! Oh, if only they were like youuuuu!!! You used “it” (I assume you’re reference to ‘it’ being a 12-step program, and not a giant stick to whack things with), but they didn’t. If only they were like you and used it!!
      That is the braying pompousness in meetings that I’ve happily avoided for so many years.The constant self immolation of character to validate positive affirmation by so many people in the “program”. It’s sad.

      If only people knew there were other ways that may work for them than 12-step. Oh right, they do.
      But often the attendance of many 12-step meetings is because those people were forced to go by a court. And they have to keep going until they agree with the “program” or else they get shunned and the court is let aware they are not complying.
      If you’re in rehab, you can’t leave, or “graduate”, until you agree with all your told, and accept every diagnosis given. That’s not recovery. That’s initiation. It’s indoctrination. A full on effort to promote a cult like mentality.

      While 12-step may work for some, it sure doesn’t work for everybody.So, good for you for being self-centered. I’m sure the sights are grand from the top of your moral pedestal.

      • disqus_Quri44IJyq

        Exactly right – court mandates to religious groups masquerading as evidence-based treatment is ludicrous.

      • thederbycitygirl .

        Peace to you – thank you for sharing your thoughts – you may be right!

    • Groucho

      I don’t usually do this but I must “call out” thederbycitygirl for your comments. First you question the author’s opinions because you looked her up on Wikipedia and she doesn’t appear to have an undergraduate or advanced degree so you imply that she is therefore unqualified to write the article. What you failed to discover in your “research” is that Ms. Szalavitz has coauthored 3 books with 2 different psychiatrists. And if you had looked up Ms. Szalavitz’s real biography (easy to find) you would have discovered that she is a former cocaine and heroin addict and her area of expertise as a journalist is mental health and addictions. I do have a Master’s Degree and one of things that was taboo when doing research for scholarly papers was using any kind of Wiki.
      I applaud you for your 24 years sober and if AA helped you, then great, anything that works. But then you go on to recite AA rhetoric (surrendering self-will etc.) Scientifically, it’s not about will or will power, it’s a disease that in most cases is better treated by medicine than by faith. If I had prayed for my hereditary hypertension to go away (it’s not my weight, I’m thin and active) rather than taking medication, I probably would have had a stroke 10 years ago.
      Ms. Szalavitz makes a great case for changes that need to happen in the rehab industry. I do have a minor disagreement with item 6 which I will get to later. As she points out a lot of the issues facing addiction treatment is the heavy influence that the AA 12 step model has on the industry (80-90% are 12 step or 12 step hybrids). I am not totally anti- AA/NA. I believe that anything that helps some people get and stay sober has some value, but its “one-size-fits-all” doctrine can also be harmful to some people. Also, the autonomy that each chapter has, and for that matter, each individual meeting, allows for the possibility of verbal abuse by its leaders. In a treatment center setting the abuse has the potential to be much worse especially for someone who feels that his/ her only chance is to complete the program or he/she is court ordered to be there.
      Some early members of AA heavily promoted, to whomever would listen, the idea that alcoholism (and other addictions) is a disease, but the basic doctrine of AA, especially when dealing with long time, hardline members, seems to contradict the basic concepts of how to treat a disease. AA ideals tends to blame the addict for his/her inability to get well (give oneself over to a higher power, weak, not working the steps, not ready to commit, etc.). That’s because 12 step methods are NOT BASED ON MEDICAL SCIENCE, but on the traditions of the Oxford Group, a religious sect that founders Bill W. and later Dr. Bob became involved with. I know that this has become cliché in the current argument over treatment but for what other disease do we blame the patient for not getting well or having a recurrence of the disease.
      I read that many addiction specialists believe that about 60% of addicts are trying to mask or eliminate the pain caused by a traumatic experience or other mental illness (like bipolar disorder), in other words they are self-medicating. 12 step methods do not address the person’s need to cure the mental illness or get past a personal trauma to get and stay sober.
      Resistance to the use of maintenance and therapeutic medications is another remnant of hardline 12 step doctrine. Some AA members who only have a few years sober tend to be more accepting of such medications and may even be using prescribed medications (but probably not openly revealing that they are), while the long time sober members tend to view medications as not truly being sober even with medications that are not known to be addictive. What I find hypocritical about this ideal is that the few AA/NA meeting that I have gone to, most the attendees smoke. Nicotine is a highly addictive sedative but no one seems acknowledge that fact. Unfortunately, many rehabs are either against medication or only favor short term use.
      Compounding this problem is the fact that rehabs that are in favor of using buprenorphine or morphine as maintenance for opioid addictions are limited by the FDA to 100 patients per doctor. If only such a cap existed for prescribing opiate pain killers or at least stricter guidelines for prescribing them, we might not be facing a serious opiate epidemic right now. But pharmaceutical company marketing of opiates since the mid-90s is the main culprit.
      Regarding corruption and unethical practices in the treatment industry, I agree that it needs better policing, but every industry has greedy, unscrupulous practitioners like pill-mill doctors and (again) big pharmaceutical companies.
      Humiliation and confrontation in rehabs is again an AA concept which has no basis in true psychiatric practice. Unfortunately, among the general public, ostracizing addicts is possibly worse than it is within rehabs. Thanks to addiction advocates this practice is improving especially in law enforcement but there is still a long way to go.
      Deemphasizing residential treatment is the one area that I disagree with Ms. Szalavitz. She states in the article that people tend to recover better from illness at home. In my experience those of us who are not in recovery ourselves tend to enable loved ones who are in recovery, thus sabotaging recovery. We need to teach loved ones to stop enabling, which may be more difficult than curing an addict. The alternative is to promote residential treatment that teaches addicts life skills and transitions them into the world. Many addicts do not possess life skills because the drugs stunted their maturity and/or their enablers did/do everything for them and they have no need to learn.

      • thederbycitygirl .

        Thank you for your comments. In AA/NA, Love and tolerance is our code and the only requirement for membership is a desire to stop drinking and/or using drugs. Peace to you

    • disqus_Quri44IJyq

      I have two doctoral level degrees, an MD and PhD – so I can assure you that your experience is anecdote, not proof – and sadly, these places fail far more than they succeed. Those who succeed at AA self-select for success by going. There is no magic and there is no divine wisdom at those meetings. It is time the public stopped paying people to hold them in inpatient rehabs.

      • thederbycitygirl .

        Thank you for your comments. I can only speak for myself – and I agree “by going” is essential, for me. Peace and Merry Christmas

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  • Maia –
    A very strong piece. I would add Contingency Management to your list of evidence-based practices. Not only is it an enormously powerful intervention, but also it is one of the most researched approaches in the world of addiction treatment. Here is a link to more information:


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  • Jeff Christensen

    “You cannot learn recovery skills in rehab,” he says. “The work doesn’t start till you get home.” Given that—and the expense of inpatient treatment—it makes sense to limit inpatient care to the shortest possible period necessary for medical stabilization. People also do better at recovering from all types of illness when they are surrounded by their loved ones and can sleep in their own beds.”

    Spend 10 years with an in patient facility seeing thousands of kids who can not go to or do not have their “own” bed and the ignorance of this statement protrudes like the tip of an opinionated, uneducated ice berg so deep that it will take eons to melt into reality. Hope your kids don’t become heroin addicts because this method will kill them. Longer residential treatment is needed.

    • John Gomez

      Throughout the last ten years we have learned the success rates for many of these for profit unregulated transitional living communities and unlicensed rehabs is rather low. Research has shown that after stabilization evidenced based IOP treatment appears to be as if not more affective then these programs. Plus it’s hard trying to get your insurance company to properly cover a stay at a for profit rehab followed by a stint in a halfway house. Jeff out of all people to appose such drastic changes to this industry it would be someone representing the sober home network in California. To date there is no systematic independently collected descriptive outcome data on the 12 step based programs you represent.

    • disqus_Quri44IJyq

      It’s a cheap way to feed at the public trough and make no mistake, that is exactly what 14,000 plus treatment centers are doing in large part. We have put the monkeys in charge of the zoo, literally. We don’t demand outcome studies as we would for an oncology center or hospital. It is an unprofessional group of charlatans.

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  • Frank Del Real

    In reading your article I became frustrated and confused. You described an industry that I am not familiar with even though I have been intimately involve with it for over 15 years. Frank Del Real, M.D., Medical Director, Wyoming Recovery

    • disqus_Quri44IJyq

      Denial, Dr. Frank

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  • Bob Muscala


  • David Kerr

    I want to suggest that we think of addiction as a cultural malfunction as well as a disease. I founded the TC in Newark in 1968 called Integrity House. I retired from my work in March, 2012. The TC concept has come a long way since the 1960’s. We recognize the impact of recovering peer role models, clean and sober for 10+ years, in our residential and out-patient programs. We recognize the need for changing our system of care from long-term residential help to long-term support and coaching so that self-realization and the new drug free lifestyle is internalized and practiced. I have not found much long-term recovery success for hard core criminal “lifestyle addicts” without years of interaction, support and coaching. This coaching, mentoring and support may last for 5 years or more.

    That said, most hardcore criminal addicts that I have worked with (in the thousands) need to start and become part of a culture of safe clean and sober living where each participant has a role in helping him/herself and others while learning and practicing a new positive and ethical drug free lifestyle.

    A properly functioning TC today must be sensitive to others needs and wants and what will help and what will hurt. I’ve found that those addicts I have worked with over the years need a combination of understanding, love and straight honest talk and finally the role modeling of others like them, clean and sober for over 10 years. What I didn’t expect to find was their deep understanding of their own dangerous behavior and bad choices and their strong need for others in long term recovery to help them.

    I’ve said this before; my experience supports the idea that recovery is about understanding, caring and role modeling, with or without degrees.

    Addiction today is part of our culture whether it be from middle class or affluent suburbs or getto pockets in the inner-city. If we want to make a serious impact on this disease we have to look at our own addictive behaviors! It’s what we has parents do that is having a noticeable impact on the behavior of our children. Growing addiction of mainstream white society is setting a bad example for our children and many have fallen into the deep hole that takes “fun adolescent use” of substances and, over time and with the help of genes, creates an addict.

    Let’s work together and with the media on prevention plans that will help our children grow up healthy, but these plans must start with changing our own habits and negative role modeling, mimicked by our children!

    Here’s my blogsite:

    My book, “The Voices of Integrity” can be found on or

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  • Howard Josepher

    I agree with my friend Maia that addiction treatment in this country needs a shot in the arm but she gets it wrong in where treatment came from and how we are going to get out of this mess. It is true that early therapeutic communities had there roots in the Synanon experience but their approaches were very different. Synanon was not a drug treatment program. It was a lifestyle experience, more like a cult, as people (addicts and squares) who went into Synanon were discouraged from ever leaving. The TCs were programs that had a beginning, middle and end and they were the first interventions in the US to show efficacy in helping people overcome heroin addiction. In her zest to destroy the validity of TCs, or any other self-help treatment, Maia quotes esteemed colleagues William White and William Miller’s statement 40 years after these TCs gave birth to drug treatment, that programs like these were no better than kinder alternatives. When TCs came into existence, there were no alternatives. Junkies like me had no other options, no less gentler ones. And softer and gentler treatment is not necessarily better. Any psychotherapist or treatment counselor who refuses to utilize confrontation in their practice does their patients or clients a disservice.

    Looking at the evidence of successful treatment for heroin addiction, Maia has become a zealous advocate for medication assisted treatments. Yes, they work but shouldn’t we also provide addicts with programs that can teach them skills to self-manage their health and mental health conditions without putting them on narcotics? Drug free treatment is more challenging of course but that is no reason to eliminate this important option. And, as a point of reference dear Maia, Phoenix House was investigated after it switched from a community based program to a kinder and gentler ‘professional’ model. They let go of the recovering addicts who were program graduates and TC staff and hired less confrontative social workers who ended up losing control of the facilities. Phoenix House self-destructed because they forgot where they came from which is community.

    Drug treatment in the US originated in the idea of community; one-addict-helping another. Most of us who have been there know there is a spiritual aspect to overcoming addiction. It is not so much a need for a higher power as it is a need for hope. And who is better at igniting hope than someone who has walked in the addicted person’s shoes. I cannot understand Maia’s antipathy to programs like this, whether out-patient or residential. Many of these programs employ recovering individuals and give an addicted person an opportunity to get off the street and/or learn from or model themselves after someone with the lived experience of addiction. Someone like Maia.

    There is no doubt the criminal justice system has had a negative impact on drug treatment but as long as punitive laws continue to exist, coercion from the criminal justice system is not all bad as it has worked for many of us. Sorry if the egalitarians get upset at that but I’m not sure where I’d be today if that judge didn’t mandate me to treatment 50 years ago.

    I agree with Maia in her call for standards, accreditation and evidence of effectiveness of programs. Sadly, most of the evidence we have been gathering in the US for many years has been in support of government policy (clean vs dirty) not effectiveness. Until very recently, neither NIDA nor SAMHSA would fund research or programs employing a harm reduction approach. (I know having tried and failed for 25 years.) What I would like to see is funding for experimentation; demonstration projects including both medication assisted treatments and residential and out-patient treatments. And most important, because of their effectiveness, peers or people with the lived experience of addition and mental illness. The people who bring the intangible that is often needed in overcoming addiction, the ignition of spirit and hope for a better life.

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    Where to begin. Anytime I hear someone mis-characterize the twelve step programs as “self help” and promote deadly drugs as an alternative I wonder how many decades and how many people we are going to kill before having this argument before folks start listening.
    Mind, body, spirit. It is not about finding a god, it is about aligning a sober being out of an addicted being. It is characterized throughout the first 187 pages as a spiritual malady and only part of the problem. Read the Book before making comments and judgments.
    Ask any addict who has had to detox off of methadone if you can find one who lived, you’ll get your answer about replacing organic opiates with artificial opiates. Look at the massive prescription use of our medical industry for antidepressants, opiates and ask who should be in jail.
    From the WHO, NIH, CDC; as of 2014, methadone killed more people than all other opiates combined.

  • In regards to point #1 of this article, I find it unbelievable that taxpayers are still paying for 12 Step Classes in Rehabs funded by taxpayer money.

    In 2003 Congress made this decision that HHS, SAMHSA and most State Drug Agencies choose to ignore:

    Comment: Other commenters were concerned because
    the potential for violating the requirement to separate religious and
    non-religious components of a program is heightened in the area of
    substance abuse services, which is sometimes viewed as a spiritual

    Response: The restrictions on inherently religious activities by organizations that receive funding directly from SAMHSA [1] remain the same as those described in the proposed rule.
    The Department agrees that these activities include worship, religious
    instruction, and proselytization. (Other basic examples include prayer
    meetings and devotional studies of sacred texts.) The right to maintain a
    group’s religious character does not include the right to use
    government funds to pay for inherently religious activities or

    Comment: Questions were also raised about whether 12-step programs or, specifically, AA programs, are religious programs.

    Response: With regard to the 12-step and AA
    meetings, we note that any inherently religious activities must be
    voluntary and must be offered separately in time or location from the
    program that receives direct SAMHSA funding.