© maxmitzu -
Findings from an Author’s
Four-Year Exploration
of the U.S. Addiction
Treatment System
“The Treatment Myth” –
Minneapolis Star Tribune,
“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”
Conducting the Research
Visits to 15 “rehabs
Interviews w/ > 100 staffers, leading
Review of scientific literature
Interviews w/> 100 clients
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
The Questions & the Issues
• What determines whether you should go to
• 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
• How are co-occurring problems handled in
• How are family members involved in tx?
• What happens if someone has a slip in
• What happens after you get out of rehab?
• How do you know if a program is
Myths about addiction
treatment in the U.S.
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
Myth: The 12 steps are essential
 Myth: Highly trained professionals
provide most treatment
 Myth: Most programs offer sciencebased approaches
 Myth: Most who go to tx go to overnight
residential rehabs.
 Myth: Upon relapse and return to rehab,
new approaches are used
Key Findings
One-size-fits-all approaches
 Gaps between science and
 What should protect us doesn’t
Key finding: One-size-fits-all Approaches
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
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-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.
National Treatment Center
Study, U of Georgia
Private programs (2007-8) – nearly 8 of
10 offered 12-step-based tx or
included steps in program
2/3 required 12-step attendance
> 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
Research on AA Group Attendance
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.
What’s AA’s Drop-Out Rate?
“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
What about 12-step
“No single treatment is appropriate for
everyone.” NIDA’s Principles of Drug Abuse
“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
Non 12-Step Mutual Help Groups
• 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
• Secular Organizations for Sobriety (SOS)–
views recovery as individual responsibility,
separate from spirituality/uses cognitive
• 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
it becomes severe
KEY FINDING: One-size-fitsall approaches
Everyone with a substance use
disorder needs treatment
between science & practice
Failure to use evidence-based
Overuse of ineffective approaches
Underuse of addiction
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
Failure to use evidencebased practices
“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 evidencebased practices
“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
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)
between science & practice
Overuse of ineffective approaches
“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.
between science & practice
Overuse of ineffective approaches
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.
between science & practice
Underuse of addiction medications
Approximately 2 out of 10 facilities reported
using one of FDA-approved medications for
treating alcohol problems (N-SSATS)
• naltrexone
• disulfiram
• acamprosate
between science & practice
Underuse of addiction medications
“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
“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.
KEY FINDING: What should
protect us doesn’t
 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
CASA Columbia, 2012
 Credentialing
“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. ”
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
PRINCIPLE #3: Make EBTs the foundation of your
program, but give clients a choice in the matter
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
PRINCIPLE #6: Work with families—and not just “our
family worker will do some psychoeducation with you”
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
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

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