Guest Column: Is ‘gold standard’ of drug rehab really just fool’s gold?
July 2, 2014
Medicine aspires to be a science. Research in medicine includes scientific principles like hypothesis, experimental design, placebo trails, double-blind studies, and more. Medical schools, medical board exams, hospital rules and regulations, and standards of care derive their credibility from scientific aspiration.
When you go to a physician, they should take a careful history, perform an exam, order laboratory studies, and then, based on the best science, make a diagnosis.
Diagnosis is the key to unlocking the treatment door. The correct diagnosis leads to the best available treatment.
Mental health practice follows the same paradigm. Diagnosis leads to treatment recommendations about types and levels of care,i.e. inpatient, outpatient, day care, detoxification, individual and/or group therapy, family therapy, medication and more.
You would think that all mental health and substance abuse practitioners apply the same basic principles. You would be wrong.
In a fascinating and informative new book, "Inside Rehab — The Surprising Truth about Addiction Treatment — and How to Get Help That Works," Anne Fletcher unmasks the woefully inadequate care provided by most drug rehabilitation programs.
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Mixing first-person story-telling, expert opinion, and research in equal measure, she provides a window into the under regulated, under informed and understaffed world of drug rehabilitation, a world where 2.3 million Americans received treatment in 2011.
David Lewis, M.D., of the Brown Center for Alcohol and Addiction Studies, intones of this book, "Objective, informative, and extraordinarily detailed, this book tells the truth about how addiction treatment measures up to modern science and medicine."
Adds Howard Shaffer, PhD., Associate Professor, Harvard Medical School, this "is a transformational read that distinguishes myth from reality in the murky world of addiction treatment."
There are numerous brave and revelatory findings in this book. Perhaps the most salient conclusion is that the "gold standard" of drug rehabilitation — residential treatment for 30 to 90 days away from home and the daily realities of life — is in reality usually "fool's gold."
In fact, studies indicate outpatient care tailored to the particular drug problems of a particular person is as or more effective and far more cost efficient in most circumstances.
Says Ms. Fletcher of most residential rehabs, "Common interventions include groups, lectures, rules and 'we know best' attitudes that aren't necessarily in the client's best interest and are often unsupported by science." She adds, "The field is dominated by professionals who tend to be overworked, underpaid, and less than adequately trained."
Summarizing the clinical work and research experience of Dr. Mark Willenbring, former director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), she notes the doctor insists appropriate care begins with a comprehensive evaluation from a professional trained to assess substance abuse who has no financial interest in any particular treatment program.
In fact, evaluations of his kind rarely occur, either before or after admission to most programs.
In other words, the cookie-cutter, one-size-fits-all model of most rehab programs fails to assess the uniqueness of each person, particularly those emotional strengths and weaknesses which determine the best treatment approach for that person.
Addressing the critical issue of treatment credentials, Dr. Willenbring believes that a graduate masters level degree is the minimal credential required. Adds Jeffrey Foote, PhD., co-founder of the Center for Motivation and Change in New York, "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."
Given these admonitions, it is remarkable that most rehabilitation programs are largely staffed by "substance abuse counselors" who themselves have a history of addiction and whose professional training does not meet even this minimal standard.
It is also noted that residential rehab is not the best treatment choice in many circumstances and that a quality program must have specialists trained to treat the near ubiquitous co-occurring psychiatric problems that accompany addiction.
Ms. Fletcher concludes this much needed corrective to so much of the information about the treatment of addictive disorders with the message, "Be cautious, and be skeptical" when choosing a treatment program.
In other words, truth in advertising is not a common feature of most of the "gold standard" treatment programs.
Incline Village resident Andrew Whyman, MD, is a clinical and forensic psychiatrist. He can be reached for comment at email@example.com.