Ethics and the addiction treatment industry. I’ve written about it. The New York Times, Los Angeles Times, Washington Post and others have recently written about it. The rampant ethical violations taking place in this field – in the form of body brokering, illegal enticements, drug-testing schemes, and more – are like a detestable virus infiltrating every state in the nation. But, alas, all hope is not lost. Treatment can and does work. We simply cannot throw the baby out with the bath water. Not when 22 million lives depend on it.
In my 30-year career in the addiction treatment field, I’ve often been asked what someone should look for when considering a treatment program for themselves or a loved one. I have also been asked about the critical elements of successful treatment programs by investors considering a purchase. Not surprisingly, the answers are one in the same.
Ethical, quality, successful substance abuse treatment programs are comprised of a handful of critical elements. In no particular order, these include:
Staffing & Staff Credentials. What is the treatment program’s staffing ratio and what are the staff credentials? In residential treatment, it should be very close to 1:1 clinical to patient ratio. Primary and family therapists should be licensed and have at least a master’s level education. There should be sufficient medical staff including physicians, psychiatrists, and/or Registered Nurses to address medical concerns depending on the level of care and whether or not medications are being administered. What credentials do the front-line recovery support staff have and what kind of background checks are performed on all employees? Ultimately, is the client going to be safe in this treatment environment, under the care of these people, and will they receive effective care?
Clinical Services & Evidence-Based Practices (EBPs). How many hours of clinical services – not just groups, but individual sessions too – does the treatment program deliver each week? Are they Evidence-Based Practices (EBPs) delivered with fidelity (as intended)? These might include modalities such as Motivational Interviewing, Relapse Prevention, 12-Step, Dialectical Behavior Therapy, The Matrix Model, Supportive-Expressive Psychotherapy, and Social Skills Training. Not every program needs every EBP, but they should offer some evidence-based services for patients to find what works for them. Every individual is unique and for some that may mean including medication-assisted treatments such as buprenorphine, naltrexone or others as well.
Individualized Treatment. Good treatment programs tailor their services to meet the needs of the individual. Treatment components should be different for a young adult struggling with heroin versus an older person with alcohol problems, just as it should for someone with co-occurring anxiety and depression versus someone who has been to treatment 10 times. Depending on the client, ancillary services might include life skills training like how to make and stay on a budget, debt counseling, time management, cooking skills, recreational activities and sports, sober social clubs, volunteer opportunities, exercise opportunities, educational options, or mentorship opportunities.
Family Involvement. How does the treatment center involve family/loved ones in treatment? Do they have a family program, family therapy sessions, family support groups, or couples therapy? Family can play a critical role in motivating individuals with drug or alcohol problems to enter and stay in treatment. In addition, involvement of a family member or significant other in an individual's treatment program has been shown to strengthen and extend treatment benefits. Including the family throughout treatment is critical; the absence of this is a huge red flag for concern.
Relapse Prevention Planning. Just as with the heart disease patient who falls back into their unhealthy diet, patients who relapse to drugs or alcohol should not be seen as a treatment failure. This doesn’t mean that the client has a greenlight to use again or that relapse is inevitable, but relapse is something we should be prepared for. According to the Journal of the American Medical Association, up to 60% of patients who receive substance abuse treatment will relapse within one year, and the relapse rate is even higher for some drugs like heroin. A good treatment program helps the patient and family identify a plan in case relapse occurs as well as a post-treatment monitoring program. They also inform you of what will happen in the event of a relapse during treatment, what drug testing methods they use, whether you will be billed for these, and, if so, how much.
Continuing Care. Care should not end at discharge. Professional continuing care services enhance recovery rates among adults and adolescents alike. These services might include ongoing scheduled contact between the treatment team and client/family, an alumni program, and on-site support groups. Keeping patients engaged in continuing care over a period of 12 months has been shown to be an effective model for sustained recovery.
Outcomes. Understanding optimal substance abuse treatment outcomes can be tricky given the large number of relapses mentioned above. If a client relapses, has the treatment program failed? A program that measures and reports their outcomes as well as how they define success is the goal. Success can be evaluated through performance monitoring or outcomes tracking, client and employee surveys and engagement, and analyses of admissions and retention data. Top performance and outcome measures can include a successful transition between levels of care (IP-OP, e.g.), toxicology screening (abstinence, decreased use, etc.), increased employment and quality of life, decreased discharges against medical advice, less ER visits, and reduced psychiatric symptoms.
Other considerations include accreditation, how patients are linked to the next level of care, and the aesthetic qualities of the program – is it a clean environment with necessary amenities, quality food, and appropriate maintenance? A treatment program doesn’t have to look like a 5-star resort on a beach, but it should be clean and comfortable.
Looking for a treatment program during a time of crisis can be daunting, so having this list of what to ask about can hopefully ease the burden. Don’t be afraid to ask questions or trust your gut. We are sadly living in a time of transition and crisis in the field of addiction treatment and until we can get basic regulations formalized, it is up to the consumer to do some investigating.
Need help with substance abuse? In the U.S., call 1-800-RECOVERY or 800-662-HELP (4357) for the SAMHSA National Helpline.