Join Together chats with New York Times best-selling author Anne Fletcher, MS, RD, whose latest book is “Inside Rehab: The Surprising Truth About Addiction Treatment – And How to Get Help That Works” (Viking, 2013), to discuss addiction treatment today and the future of recovery. Drawing on her experience visiting rehabs across the country, interviewing treatment clients and providers, and analyzing research, Fletcher shares her insight for parents seeking help with their child’s drug or alcohol problem.
After reading Inside Rehab, a number of parents who have experienced addiction and treatment with their children have emotionally thanked you for “validating their own experiences.” What do you, as the author and a parent, think that means about the book and its impact?
Fletcher: After visiting treatment facilities (of different types and sizes) and interviewing more than 200 clients, staffers, and experts in the field, my findings let readers know that they’re not alone in finding that the widely espoused motto, “Treatment works” isn’t always true. It’s reassuring to hear that problems often lay within the treatment system itself, not within the client. How very sad it is when people spend tens or even hundreds of thousands of dollars to go to treatment over and over again, only to be offered the same kinds of approaches each time, and to be faulted when treatment fails. It’s incredibly validating to read that many others have had similar experiences and to have experts voice how broken a system like this is.
You are highly critical of addiction treatment as it is practiced today, and yet you are resolutely hopeful about recovery and about addiction treatment in the future. Can you explain that dichotomy?
Fletcher: I continue to have concerns, particularly when the Affordable Care Act is fully implemented and the already overburdened addiction treatment system becomes further taxed as increasing numbers of people have access to treatment. Unfortunately, some recent personal experiences trying to find quality treatment for a loved one have reinforced my negativity, although my impressions of the kindness and generosity of people working within the system have been reaffirmed. Also, I saw encouraging signs toward the end of writing the book that programs are continuing to incorporate evidence-based treatment practices. Finally, facilities using innovative state-of-the-art models of care are gaining momentum – for instance, the Center for Motivation and Change in New York, Practical Recovery in California, and Alltyr in Minnesota.
Based on all your research and discussions with the top experts, what do you advise parents who are looking for help with their child’s drug or alcohol problems?
Fletcher: Be thoughtful, do homework, and don’t rush into things. Most people with substance use disorders don’t need to go to a formal treatment facility. There’s not much research to guide us about how adolescents overcome substance problems, but we know that the vast majority of adults recover without setting foot in a treatment program. Instead, they achieve sobriety on their own, by going to a mutual help group (such as AA/NA, SMART Recovery, or Women for Sobriety), or receive individual therapy. Treatment programs are designed for people with severe substance use disorders, not for the far greater numbers of individuals with mild to moderate problems. If looking for help for my child, I’d start with individual therapy with a mental health professional specializing in treating substance use disorders and the underlying psychological issues that so many young people with drug and alcohol problems have. (Guidelines within specialties are offered in Inside Rehab.)
I’d seek out facilities that provide evidence-based approaches for teens with substance problems such as multi-dimensional family therapy (MDFT), the adolescent community reinforcement approach (A-CRA), and The Seven Challenges. (Guidelines for locating them are offered in the book.) Also, studies repeatedly show that the most effective way to help such teens is with true family therapy. Yet not one facility I visited offered any of these approaches. Most programs incorporate the 12-steps, an approach for which there is no controlled research support in adolescents. Although a number of studies suggest that teens who become involved in AA after treatment are more likely to remain abstinent than those who don’t, most teens don’t affiliate with 12-step meetings and many who do, drop out over time. That stated, 12-step meetings are a good way for youth to meet and socialize with non-using peers.
Since there appears to be increasing scientific acceptance of addiction as a “disease,” why isn’t it treated with the same kind of medical- and outcome-driven approaches as other diseases?
Fletcher: It’s very hard to define what a successful outcome is. Most now agree that it can’t just be abstinence. Although that’s the ultimate goal, we have to look at less frequent use as well as improvements in quality of life. While many programs claim to use evidence-based treatment strategies, researchers find that very little science-based practice actually goes on in the field. I think a lot of it has to do with lack of professionalization. So many well-intentioned people go into this field, but as the 2012 CASA Columbia report, “Addiction Medicine: Closing the Gap Between Science and Practice” revealed, more than half the states don’t require even a bachelors degree to become a certified or licensed addiction counselor. As one expert in my book said, “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.” I also found that accreditation and state licensing do not assure that facilities deliver evidence-based or, in certain cases, even safe treatment.
Many families believe that getting loved ones into rehab is 99% of the process, but you point out that “sustaining recovery” and “recovery management” are equally important to long term success. Can you explain that?
Fletcher: The struggles of those with serious substance use disorders often wax and wane, sometimes over a lifetime. (Individuals who have trouble with their weight might “get” the analogy.) As they exit treatment, many clients need care that continues indefinitely, including individual on-going professional support and from mutual help groups and recovery community organizations. This is often hard to find. One woman I interviewed went to a prestigious residential rehab, then to their outpatient program, hoping to continue afterwards with her outpatient counselor on an individual basis. To her dismay, she was told, “Sorry, we’re not set up for this. You can start outpatient treatment again.” As a person in long-term recovery myself, I’ve had an addiction professional in my life for many years whom I know I can see, even for a single appointment, whenever I need support. My suggestion to many turning to me for advice is, “You need a ‘George’ in your life.”