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An eye-opening tour of the addiction treatment industry explores the gap between what should happen and what does
What happens inside drug and alcohol rehabilitation centers and how rehab works are a mystery to those outside the industry – and sometimes even to those inside it.
Anne M. Fletcher is a trusted New York Times bestselling health and medical writer who visited 15 addiction treatment centers—from outpatient programs for the indigent to famous celebrity rehabs; from the sites of renowned Twelve-Step centers to several unconventional programs—to find out what really happens. What she reveals ranges from inspirational to irresponsible, and, in some cases, potentially dangerous.
Real Stories: As always with her books, Fletcher gets the inside story by turning to real people who “have been there,” interviewing more than 100 individuals whose compelling stories illustrate serious issues facing people in rehab and endemic in the rehab industry today.
Connected Writer and Researcher who has earned the respect (and cooperation) of experts throughout the fields she’s taken on. Inside Rehab is no exception—Fletcher has interviewed more than 100 professionals working in the field, including a mix of rehab staffers and administrators as well as leading academics.
Rehab is constantly covered in the media, as celebrities battle their drug and alcohol issues in the spotlight and reality TV puts recovery in prime time. Addiction is no longer only a personal struggle—it’s a pop culture phenomenon.
Myth Busting: Fletcher exposes twelve supposed facts for the falsehoods they are, including “rehab is necessary for most people to recover from addictions;” “highly trained professionals provide most of the treatment in addiction programs;” and “drugs should not be used to treat a drug addict.” Fletcher’s most important finding is the alarming discrepancy between the treatments being employed at many rehab centers and the treatments recommended by leading experts and supported by scientific research.
Guidance and Practical Solutions: Inside Rehab also highlights what is working, spotlights state-of-the-art programs and practices, and offers advice and guidance for people seeking quality care and treatment for themselves or those they care about.
Inside Rehab is the first book to give readers a thoughtful, sensitive, and bracingly honest insider’s view of the drug and alcohol rehab industry in America. For people seeking quality care for themselves or a loved one, Inside Rehab is essential reading, offering a wealth of accurate information and wise guidance.
- Sales Rank: #373867 in eBooks
- Published on: 2013-02-07
- Released on: 2013-02-07
- Format: Kindle eBook
From Publishers Weekly
Starred Review. Some things never change. And as Fletcher (Sober for Good) finds in this bold report on 15 rehab facilities—from high-end, celebrity-friendly outposts to those treating people on welfare—that fact especially pertains to addiction treatment. Collecting stories from more than 100 interviews, Fletcher methodically dissects the myths about the programs that treat 2.5 million people every year. She finds, for example, that rehab isn't necessary for recovery—some heal on their own, attend self-help groups, or see therapists; that most of the treatment in rehab programs is handled not by highly trained pros but by counselors with varying levels of education and training. She debunks myths, such as that the 12 steps of Alcoholics Anonymous are essential for recovery. Fletcher concludes that traditional programs, such as group treatment, 12 step programs, and counseling, work for some but not for all. Dimitri, for instance, began abusing drugs at 15 and cycled in and out of programs that failed to help him. Fletcher also highlights the exorbitant cost of rehab: one young woman's treatment drained her parents of ,000. Fletcher presents what works, why, where to find it, and how much it costs. It's startling, difficult, and important information for those traveling toward recovery, and anyone who wants to help. (Feb.)
From Booklist
*Starred Review* Health writer Fletcher adopts a cautious, even skeptical approach in her exploration of current treatments of substance abuse. She warns that her book “is filled with disturbing accounts of seriously addicted people getting very limited care at exhaustive costs and with uncertain results.” Indeed, her portrait of contemporary addiction treatment incorporates numerous stories of individuals who’ve undergone treatment, opinions and commentary from experts in the field, and her own visits to 15 different rehab programs. More than 13,000 addiction treatment programs—outpatient, residential, and hospital inpatient—operate in the U.S. Dropout rates and the frequency of one-year relapses are high. One expert laments, “When it comes to picking a rehab, most people ask more questions before buying a vacuum.” Fletcher has no such bashfulness and provides answers to fundamental questions: How much does it cost? How long does it last? What do people actually do there? She concludes that no particular treatment of substance abuse is superior to others for most individuals. Flexibility—as opposed to a “one-size-fits-all” approach—matters most. One authority on addiction agrees: “There are as many roads to recovery as there are individuals.” Inside Rehab is a valuable road map for navigating the multiple pathways and programs dealing with the problem of substance abuse. --Tony Miksanek
Review
"It's startling, difficult, and important information for those traveling toward recovery, and anyone who wants to help." ---Publishers Weekly Starred Review
Most helpful customer reviews
160 of 167 people found the following review helpful.
I only wish this book had been written 15 years ago!
By Mona Lisa
Fifteen years ago, I sat shaking with a phone book in my hand. I had reached the end of a 25 year addiction to alcohol and I was desperate. I had decided to quit drinking and I knew, or at least I assumed, that I had to go to rehab to do it.
I'd heard many times that addiction is a disease so I naively assumed that it was treated like other diseases. You called the hospital and they helped you get better, using proven scientific protocols. So based on this assumption, I picked up the phone book, called a local hospital that had an affiliated rehab, and scheduled an appointment.
Since over 90% of rehabs in the late '90s were completely 12 step based, I naturally found myself in a 12 step based program. The main goal of the program was to connect clients to the 12 step community and convince them that the sole path to recovery was lifelong participation in a 12 step group. Its educational component consisted of movies, photocopied literature, and discussions about AA and the 12 steps. We worked steps, and the steps were posted on the wall of every room in the rehab. The sole clinical "credential" of the counselor I saw was that he had been an AA member for nearly 20 years (he did have a masters degree in an unrelated field). In retrospect I should have understood that there was nothing scientific about this experience, but I didn't question it as I might have under other circumstances. It is tough to be an educated consumer when your brain is addled with chemicals; tougher still to question authority when you are beaten down and full of shame as the result of an addiction.
But despite what I'd been taught in rehab, I just didn't care for AA. I thought the people were (mostly) nice and well meaning, and I found the social support helpful, but I saw the underlying premise of the program (that the power to recover comes from a "Higher Power"--from OUTSIDE the individual) as being illogical and counterproductive. It seemed to me, both in rehab and in AA, that the focus was more on finding a connection with this outside force than on actually learning skills to live life.
This led to a terrible internal conflict. Although I felt a deep disconnect with AA's philosophy, I'd learned in rehab that such thoughts were evidence that I was still sick. They were "the disease talking." So instead of moving on, I devoted myself to the program. I "acted as if": I got a sponsor, I worked the steps repeatedly, I went to meetings frequently (every day for the first two years), I sponsored others, I took on service positions...and I kept waiting for the moment when I'd finally "get it."
Days, months, and years of sobriety passed, but that moment never came. It was nearly a decade later--a decade of painful mental gymnastics later--before I finally came to the point where I understood that I wasn't "acting as if," I was living a lie. The truth was that AA was not a good fit for me, never had been, and never would be.
I decided to leave, but leaving was tough, almost as tough as quitting my addiction was. Even though the program had never made sense to me, I'd made such an effort at adapting myself to it that it took a couple of years before I could unravel what I really thought and felt. I essentially had to recover...from recovery.
This is not to bash AA or denigrate the recovery of those who find it helpful. It is simply to back up one of the many excellent points that Ms. Fletcher makes in this important book: one size does not fit all. Addiction treatment should be individualized. No one recovery pathway should ever, EVER be sold as "the only way." No person seeking recovery should ever, EVER be told that they are hopeless and doomed to die unless they follow a particular protocol.
I sincerely hope that anyone who is considering rehab will read this book before making any decision about how to proceed. Making your treatment choice carefully may save your life, your wallet, your sanity--or all three.
95 of 100 people found the following review helpful.
Thinking about rehab? You need this book!
By Arthur Horvath
Anne Fletcher became controversial in 2002 when she released the best-selling Sober for Good: New Solutions for Drinking Problems -- Advice from Those Who Have Succeeded. The book was based on her interviews with 222 "masters," individuals who had overcome drinking problems for at least five years. She was fiercely criticized by members of the addiction treatment industry because of the diversity of her recovery accounts, and her support of the idea that there are many paths to recovery (including moderated consumption). Nevertheless, her book earned awards from scientific societies. Her current book, Inside Rehab, will also be controversial. Controversy seems inevitable when an author is dedicated, as Ms. Fletcher is, to staying close to the scientific literature, and is writing about a field that does not have a similar motivation.
Inside Rehab describes current practices in the US addiction treatment industry, based on in-depth visits to a diverse sample of 15 facilities (including Practical Recovery, the San Diego addiction treatment system I founded and operate), and interviews with approximately 100 experts and facility staffers. She also interviewed dozens of treatment clients, who report their treatment experiences good and bad. What Ms. Fletcher documents should frighten anyone seeking US addiction treatment (including "rehab," the common term for residential treatment).
On average the US treatment system has a one-size-fits-all approach based on the 12-step approach to recovery. Some facilities do a good job, at a reasonable price, in providing this approach. However, most facilities suffer from under-qualified staff, failure to provide sufficient individualization of treatment, failure to provide the latest evidence-based practices, and failure to offer the client adequate information about treatment options. Among the evidence-based practices that are lacking are addiction medications (such as methadone or buprenorphine), which many facilities simply refuse to make available, inadequate assessment practices, and failure to include psychosocial approaches known to work while including others (e.g., confrontation) known to make people worse.
You may think Ms. Fletcher is exaggerating or misrepresenting what she found. Consider a statement in the Handbook of Alcoholism Treatment: Effective Alternatives (3rd ed., 2003, edited by Hester & Miller), in a chapter entitled "What Works? A Summary of Alcohol Treatment Outcome Research," by Miller, Wilbourne and Hettema. They state that "the negative correlation between scientific evidence and treatment-as-usual remains striking, and could hardly be larger if one intentionally constructed treatment programs from those approaches with the least evidence of efficacy." The 2nd edition of this book (1995) reached the same conclusion.
Or consider how similar her findings are with the report "Addiction medicine: Closing the gap between science and practice" released August, 2012, by the National Center on Addiction and Substance Abuse at Columbia University (CASA Columbia). The report's findings are summarized in the press release: "While a wide range of evidence-based screening, intervention, treatment and disease management tools and practices exist, they rarely are employed. The report exposes the fact that most medical professionals who should be providing treatment are not sufficiently trained to diagnose or treat addiction, and most of those providing addiction treatment are not medical professionals and are not equipped with the knowledge, skills or credentials necessary to provide the full range of evidence-based services, including pharmaceutical and psychosocial therapies and other medical care."
An introductory chapter identifies myths (e.g., "most people need to go to rehab; group counseling is the best way to treat addictions; highly trained professionals provide most of the treatment in addiction programs") and identifies the facilities visited. The following nine chapters address what it's like inside a rehab, what it costs, what rehab should look like, why rehab is not needed for most addiction problems, how one-size-fits-all treatment is problematic, why teen treatment should be different than adult treatment, what to do when mental health problems co-exist with addiction problems (this "co-morbidity" is common but the lack of licensed mental health professionals in most facilities means it is commonly unaddressed), the importance of long-term care (and not relying on rehab as a quick fix), and knowing what to look for in a rehab. A companion e-book, Holistic Rehab Therapies: Are Alternative Addiction Treatments Helpful, Harmful, or Head Games? is timely because so many high-end rehabs incorporate holistic healing into their services.
For addiction professionals with a science-based perspective on recovery, and the opportunity to listen to individuals who had been through US treatment facilities, Inside Rehab contains no major surprises. We have known for decades the generally poor state of affairs in US addiction treatment. For years I have heard first hand accounts of how individuals actually get treated (it's bad) in even well-known facilities. However, it is exciting to see such a highly respected author report on this situation so thoroughly and systematically. With luck this book will help increase support for real change.
A major strength of the book is the positive emphasis on how to screen an addiction treatment facility. For many the final chapter, combined with the Appendix ("A consumer checklist for checking out rehabs") will by themselves be worth the price of the book. The book also points to resources from the non-12-step world. These resources are typically not provided to clients in 12-step oriented facilities. Instead these clients may hear that "12-step is the only thing that works." In fact the 12-step approach (either in 12 step groups alone, or in 12-step oriented treatment) is indeed helpful to many, especially if attendance is freely chosen. However, 12-step based recovery is a small portion of the entire group of people who recover from addiction.
How could the US addiction treatment system have been so bad for so long? I speculate that the feedback systems normally in place when consumers purchase services exist only minimally in this system. Addiction clients have been almost voiceless. When they complain they are told "that's your disease talking" rather than being listened to. Indeed, addiction clients have much to learn about recovery and about life, but they also have much to teach us about these same issues. Ms. Fletcher is to be commended for giving a powerful and compelling voice to these often mistreated individuals.
A. Tom Horvath, Ph.D.
Practical Recovery
65 of 73 people found the following review helpful.
Residential treatment needs to be better, not eliminated
By C. Brown
While I agree with many of the criticisms of the treatment field in Fletcher's book, such as that most treatment is 12 step based with not enough alternative, that not enough individual therapy is provided, that many counselors are undertrained, and that 28 day residential rehab as a stand along is not enough, I don't agree with her that residential treatment is mostly unnecessary. I don't think people are being overtreated--it is the 90% of people who do not get treatment and need treatment that is the problem. Treatment absolutely needs to be much better, but that does not mean residential treatment is not needed for various reasons. Combining residential treatment with a gradual step down to outpatient treatment over a period of months is offered by many treatment centers, not just 28 days. The problem with non-12 step based treatment is one of access and affordability. If one is to go to residential treatment for a few weeks only before outpatient, and for the family to attend family groups, the center must be close to one's home. Insurance coverage would be helpful, if not a necessity. So if there is no non-12 step program near one's home or covered by one's insurance as was my case for my son, I had to work with a 12 step based program.
Under my insurance neither the HMO or PPO provided residential treatment, so I ended up paying for residential. Here is why: My son went to numerous individual counselors specializing in addiction and various outpatient treatment programs and kept getting worse because he wanted to keep using and found ways to use substances even while in treatment and went back to heavy using as soon as he stopped the treatment. When he finally got to the point of seriously trying to make treatment work for him, he had suffered many consequences and was in crisis and was totally dysfunctional. People who go to residential treatment in my experience usually need it because: they have been arrested or jailed, sometimes numerous times, for DUIs, drug possession, assault, etc., they have overdosed on opiates or alcohol and might have died (many people do) or ended up in the emergency room, they became manic or psychotic or suicidal or depressed from substance abuse and ended up on the psych ward, they flunked out of college for the second time, they lost their jobs, never had one in the first place, and their parents or spouses kicked them out of their house and they are living homeless on the street or in somebody's garage, they were told by their doctor that if they drink or use again they will suffer organ failure and die, they lost custody of their kids, etc. Fletcher sounds like my insurance company when she says people are going to have to learn to live in the real world and rehab is not the real world. That is very true--but people in crisis need to be in a calm and isolated environment to regain their health and mental faculties, take meds, and eat healthy food and develop a routine schedule before returning to the "real" world. Their lives are in shambles and taking them out of the chaos is really necessary at that point.
Now maybe this is not MOST people who need treatment and maybe MOST people can stop on their own, but since this book is about rehab, I expected the author would focus on THOSE WHO NEED IT in the book. And most people who need rehab have to be somewhat coerced or cajoled or mandated into treatment, and from what I have read, evidence shows that those who go voluntarily don't necessarily do better than those who do not.
Regarding AA based programs, I myself wanted to find a non-AA alternative, and non-AA support groups like SMART RECOVERY would be my first choice, but there is a huge advantage to AA, which is why I think it is not so bad for a treatment center to recommend and encourage AA. I don't have many SMART RECOVERY groups in my area--the nearest ones are an hour away which meets 2 or 3 times a week. But one can find an AA or NA meeting every day, several times a day, within about 10-20 minutes of my house. AA does maintain that one should "keep coming back" and stay in recovery, but at least so far, my son is finding it useful to maintain sobriety. If he can maintain sobriety without AA eventually, then no one is going to force him to go to AA meetings for the rest of his life, but there are worse things, such as the situations I mentioned above. The treatment facility I chose has an aftercare program for a year, as many do, but also recommends AA meetings and working with a sponsor to supplement that. If treatment centers don't support the idea of AA or take them to some meetings, people will not tend to use this resource which is the most available help there is. My biggest gripe with treatment and AA which Fletcher does't mention is the smoking. Compared to dying immediately of an overdose, smoking is a slower death, and some people may be further put off from treatment if not allowed to smoke, but I read that evidence shows that smokers are 25% more likely to relapse. I think more thought needs to be put into this issue.
A couple other points: Fletcher suggests it is not a good idea to mix clienta of different ages, and that grouping younger people together would be best. For adolescents, yes, but I found that older people can be helpful to younger addicts in many ways and can act as mentors. Also, centers treating about 10-20 people at a time may not have that luxury. Regarding individual therapy, I believe both group and individual therapy are necessary, and I think if the treatment center does not offer enough, after a few weeks or during outpatient treatment, there is no reason why a person cannot also see a therapist or even two on an individual basis to augment treatment. My insurance covers unlimited individual therapy if the therapist is in network, so supplementing can be done if that piece is missing for those with insurance. A Sober Livig House is another good option, but they don't usually provide food or transportation so are not a good substitute for residential treatment in the early days.
If new recovery groups arise and if treatment centers adopt more "evidence based" therapies and insurance companies don't obstruct people from getting the help they need, including residential treatment, I would be so happy, but in the "real" world, it hasn't yet happened, and as a consumer, I am not sure I want to follow the footsteps of the person Fletcher mentions who spent $500,000 and still hasn't recovered, whose advice she quoted at length. I do think that if one thing doesn't work, it is insanity to keep doing it over and over, so if there is a next time I will do something different.
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