1. Inside Rehab: Findings from an Author’s Four-Year Exploration of the U.S. Addiction Treatment System © maxmitzu - Fotolia.com

2. “The Treatment Myth” – Minneapolis Star Tribune, 1993   “Chemical dependency programs exaggerate their success rates”   “Treatment has little scientific support”   “For many clients it’s a revolving door”   “Even an elite treatment program has many failures”

3.  Visits to 15 “rehabs  Interviews w/ > 100 staffers, leading experts experts  Review of scientific literature  Interviews w/> 100 clients Conducting the Research

4. Goals – To…   Give consumers a realistic picture of what goes on in residential / outpatient rehab   Uncover myths and facts about treatment   Address issues faced by people in rehab and by the industry   Provide guide to different types of treatment and ways to recover   Inform consumers about science-based practices and spotlight facilities using them   Provide guidance for finding quality treatment

5. What determines whether you should go to rehab? How do most people choose a rehab? How is rehab financed? Does more expensive tx = better tx? Who are rehab treatment providers? What do people actually do in rehab? The Questions & the Issues

6. How are co-occurring problems handled in rehab? How are family members involved in tx? What happens if someone has a slip in rehab? What happens after you get out of rehab? How do you know if a program is effective? The Questions & the Issues

7.   Myth: 30 days is long enough   Myth: More money buys better treatment   Myth: Group counseling is the best form of tx   Myth: Drugs shouldn’t be used to treat a drug addict   Myth: To recover, most people need treatment Myths about addiction treatment in the U.S.

8.   Myth: The 12 steps are essential   Myth: Highly trained professionals provide most treatment   Myth: Most programs offer science- based approaches   Myth: Most who go to tx go to overnight residential rehabs.   Myth: Upon relapse and return to rehab, new approaches are used

9.  One-size-fits-all approaches  Gaps between science and practice  What should protect us doesn’t Key Findings

10.  Group counseling for everyone “I don’t like groups—they make me uncomfortable. I have never shared in my life at a 12-step meeting. It seemed that my stories were way worse than others’, and it made me not want to share.” Sarah J. Key finding: One-size-fits-all Approaches

11.  Same assignments for all “It’s a cookie-cutter approach. I felt like I was part of a herd...Everyone seemed to be working on the same thing; we all seemed to be on the same path.” Elizabeth F. Key finding: One-size-fits-all Approaches

12.  12-step ubiquity “I personally do not know of a single program—other than methadone programs for heroin addicts—that could reliably be characterized as anything other than 12-step.” Tom McLellan, Ph.D. Key finding: One-size-fits-all Approaches

13. Private programs (2007-8) – nearly 8 of 10 offered 12-step-based tx or included steps in program 2/3 required 12-step attendance 2/3 required 12-step attendance > 50% held 12-step meetings on-site > 50% held 12-step meetings on-site Public programs (2009–10) ~ 7 of 10 based primarily on 12-step model or included 12-step component National Treatment Center Study, U of Georgia

14.  Studies show “a positive but modest association between AA attendance and abstinence.” Scott Tonigan, PhD  Individuals who attend AA frequently more likely to become & stay abstinent over short and long term.  AA involvement may substantially reduce need for more costly professional care. Research on AA Group Attendance

15.  “Studies to date generally show that only about 25 - 35% of those who attend one meeting of AA go on to active participation.” Tom McLellan, PhD  “Overall, studies suggest that between 55 and 80% of alcoholics encouraged to attend AA while in treatment will stop attending AA within 9 months.” Scott Tonigan, PhD Scott Tonigan, PhD What’s AA’s Drop-Out Rate?

16. What about 12-step facilitation?

17. “No single treatment is appropriate for everyone.” NIDA’s Principles of Drug Abuse Treatment “We have the right – as do our families and friends – to know about the many pathways to recovery.” Recovery Bill of Rights, Faces and Voices of Recovery “We have the right – as do our families and friends – to know about the many pathways to recovery.” Recovery Bill of Rights, Faces and Voices of Recovery “The research evidence clearly demonstrates that a one-size-fits-all approach to addiction treatment typically is a recipe for failure.” Addiction Medicine: Closing the Gap Between Science and Practice, CASA Columbia, 2012

18. SMART Recovery (Self-Management and Recovery Training) – based on cognitive-behavioral principles and motivational interviewing SMART Recovery (Self-Management and Recovery Training) – based on cognitive-behavioral principles and motivational interviewing Women for Sobriety – employs 13 statements emphasizing self-worth, emotional/spiritual growth, not dwelling on the past, personal responsibility, problem solving Women for Sobriety – employs 13 statements emphasizing self-worth, emotional/spiritual growth, not dwelling on the past, personal responsibility, problem solving Non 12-Step Mutual Help Groups

19. Secular Organizations for Sobriety (SOS)– views recovery as individual responsibility, separate from spirituality/uses cognitive approach Secular Organizations for Sobriety (SOS)– views recovery as individual responsibility, separate from spirituality/uses cognitive approach LifeRing –uses group process (secular) to empower the “sober self” within each participant to work out own path to sobriety LifeRing –uses group process (secular) to empower the “sober self” within each participant to work out own path to sobriety Moderation Management – uses CBT principles to cut back or quit drinking before Moderation Management – uses CBT principles to cut back or quit drinking before it becomes severe it becomes severe

20.  Everyone with a substance use disorder needs treatment KEY FINDING: One-size-fits- all approaches

21.   Failure to use evidence-based practices   Overuse of ineffective approaches   Underuse of addiction medications KEY FINDING: KEY FINDING: Gap between science & practice

22. Evidence-based practices   Cognitive-Behavioral Therapy   12-Step Facilitation   Motivational Interviewing   Contingency Management   Behavioral Couples Therapy (Family therapy for teens)   CRA (Community Reinforcement)   CRAFT for families

23. “Perhaps the most alarming finding was that what the researchers termed ‘chat’ occurred much more frequently than science-based interventions. Often, the counselors revealed personal things irrelevant to the client’s issues.” “Perhaps the most alarming finding was that what the researchers termed ‘chat’ occurred much more frequently than science-based interventions. Often, the counselors revealed personal things irrelevant to the client’s issues.” Kathleen Carroll, Ph.D.,et al, Yale Failure to use evidence- based practices

24. “There was a lot of checking in with clients to see how they were doing, very little content in the areas of relapse prevention and CBT, and a lot of winging it…” “There was a lot of checking in with clients to see how they were doing, very little content in the areas of relapse prevention and CBT, and a lot of winging it…” Adam Brooks, Ph.D., TRI Adam Brooks, Ph.D., TRI Failure to use evidence- based practices

25. CRAFT – Community Reinforcement & Family Training  Produced 3X more pt engagement than Al-Anon/Nar-Anon and 2X that of Johnson intervention  Overall, CRAFT encouraged ~ 2/3 of treatment-resistant patients to attend treatment Roozen, et al (Review) Addiction, 2010)

26.   Overuse of ineffective approaches KEY FINDING: KEY FINDING: Gap between science & practice LECTURES and VIDEOS – “After we all checked in, they typically showed a video of something and talked about it. We spent too much time replaying videos on how your brain works.” Sadie A.

27.   Overuse of ineffective approaches KEY FINDING: KEY FINDING: Gap between science & practice DWELLING ON THE PAST: “The message was that you were born a drunk and will always be one. Look at your life and the consequences of your actions. Very little time was spent on creating a future once you cleared an area in your life.” Eddie F.

28.   Underuse of addiction medications KEY FINDING: KEY FINDING: Gap between science & practice Approximately 2 out of 10 facilities reported using one of FDA-approved medications for treating alcohol problems (N-SSATS) naltrexone disulfiram acamprosate

29.   Underuse of addiction medications KEY FINDING: KEY FINDING: Gap between science & practice “Fewer than 10 percent of all people dependent on opioids in the United States are receiving substitution treatment... The continued use of methadone and buprenorphine to detoxify patients from opioids is the most damaging aspect of current treatment of opioid dependence.” Health Affairs 32, no. 8, 2013

30. “A miracle drug” “In the past, I always wanted to use—it always consumed me before. This is the one thing that Suboxone has taken away from me. Now, I can sit and read a book.” Curtis M.

31.   Accreditation   Credentialing KEY FINDING: KEY FINDING: What should protect us doesn’t

32.  Accreditation In facilities subject to state regulation, staffing requirements do not consistently mandate involvement of professionals capable of providing a full range of effective interventions... “For no other health condition are such exemptions from routine governmental oversight considered acceptable practice.” CASA Columbia, 2012

33. “ ” “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. ”  Credentialing

34. Principles for a State-of-the-Art Rehab Jeffrey Foote, PhD, Ctr for Motivation and Change, NY PRINCIPLE #1: Hire highly qualified staff, pay them what their qualifications deserve, and keep them happy doing the very hard work they do PRINCIPLE #2: Keep track of how you’re doing and have it be a transparent, nonthreatening support system PRINCIPLE #3: Make EBTs the foundation of your program, but give clients a choice in the matter

35. Principles for a State-of-the-Art Rehab Jeffrey Foote, PhD, Ctr for Motivation and Change, NY PRINCIPLE #4: Train, supervise, and retrain staff in EBTs (a huge job) PRINCIPLE # 5: Hire therapists who can demonstrate empathy and run an organization that backs up this value PRINCIPLE #6: Work with families—and not just “our family worker will do some psychoeducation with you”

36. Principles for a State-of-the-Art Rehab Jeffrey Foote, PhD, Ctr for Motivation and Change, NY PRINCIPLE #7: One size doesn’t fi t all PRINCIPLE # 8: Address trauma... It’s not all about drugs. PRINCIPLE #9: Embed treatment in life, understand substance use in the context of a person’s life, and recognize the importance of helping clients develop a full life to compete with the pull of their substance use