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Anne M. Fletcher, M.S., R.D.
Anne M. Fletcher M.S., R.D.

When Addiction Treatment is One-Size-Fits-All

Cookie-cutter treatment is all too common at our drug and alcohol rehabs.

Wyatt D. said his years-long heroin addiction took him to residential rehab “probably at least 12 times”, which cost “over a million dollars.” He added, “I always went right back to using drugs, sometimes within hours after getting out.” Although he never connected with the 12-step philosophy, he wasn’t offered an alternative until he went to the non-12-step rehab where I interviewed him in 2009. When I asked why he kept going back to the same kinds of places, he said, “I didn’t think there was anything else. If I’d bring up any alternatives to the 12 steps, they’d be frowned upon, and I’d be told they wouldn’t work.” Just as I was finishing writing Inside Rehab last summer, I received a heartbreaking e-mail informing me of 37-year-old Wyatt’s drug-related death.

Mark Willenbring, MD, former director of the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism and founder of the new Alltyr treatment clinic in St. Paul, Minnesota, affirmed what I heard so often: “I keep coming across patient after patient who has been through rehab with either no benefit or with negative effects. Since really diving into clinical practice in the private sector, my tolerance for the existing way of doing business is gone. It’s atrocious that this is allowed to continue. And the treatment system systematically blames people for not responding. It’s as if you want to buy a car and there is only one model available, so you’re forced to buy it, often literally forced. Then when the car you’re sold doesn’t work, you get the blame because you drove it incorrectly.”

In researching my new book, Inside Rehab, I came across a handful of programs providing top-of-the-line treatment, but unfortunately, many of my findings showed that rehabs offer one-size-fits-all approaches to treatment:

Cookie cutter approaches. Shari P.’s mother told me, “All rehab programs basically offer the same treatments.” She should know – her daughter’s residential experiences added up to 20. Elizabeth F. found that at a prominent 12-step residential rehab, “They only know how to work one way—it’s a cookie-cutter approach. I felt like I was part of a herd.” In comparing nightly assignments with roommates, she found, “Everyone seemed to be working on the same thing; we all seemed to be on the same path.” Thomas McLellan, PhD, CEO of the Treatment Research Institute in Philadelphia, said, “A more consumer-oriented approach would be to offer different options. This would get more people into treatment and keep them longer.”

The 12 steps for all. It’s hard to find an addiction program that doesn’t involve the 12 steps of Alcoholics Anonymous. While 12-step groups help many, a review of the scientific literature by Scott Tonigan, PhD, a prolific AA researcher at the University of New Mexico, led him to conclude that about 6 to 8 out of 10 alcoholics encouraged to attend AA while in treatment will stop attending within 9 months. Yet at traditional 12-step-based residential programswhere I spent blocks of time, what I observed were full days of treatmentthat felt like they revolved around getting patients to buy into the 12 steps. Because of this pervasive focus, my overriding sense was that multiple teachable moments were missed. Unless they go to one of the few non-12-step rehabs, clients are seldom told about alternatives to AA and the fact that the 12 steps are not necessary for recovery. Not only does this violate one of the National Institute on Drug Abuse’s principles of effective addiction treatment, which states, “No single treatment is appropriate for everyone,” it can actually harm people when they’re led to believe that if they don’t connect with the established approach and (therefore) don’t do well in treatment, it’s because of some personal failing. Carrie G. said of an exclusive celebrity rehab, “I let them know that I hated AA meetings and told the tech that it wasn’t working for me. I felt punished, and was told that if I wouldn’t do it, I wouldn’t succeed. I was made to feel like there wasn’t a lot of hope.”

One nation under group treatment. I found that in a typical 12-step-based residential rehab day, there’s some type of group counseling, education, lecture, or other group activity about eight hours a day—not including meals. It may be surprising to learn how little individual counseling can go on when spending upward of $25,000 for a month at a high-end rehab. Clients at some of these places had an individual session with their addiction counselor a few times a week and for brief interludes in between sessions. And a psychologist might be seen once a week if they also had another mental health problem. At some outpatient programs, people said they received no one-on-one counseling. Despite the fact that group counseling is the predominant format, its use for addictions has not been well-researched and there is no evidence that it is critical to the recovery process. Some people benefit more from a one-one approach. Sarah J. said of her experience at traditional programs, “I don’t like groups—they make me uncomfortable. I have never shared in my life at a 12-step meeting.” When she attended a non-twelve-step program, “one of the most fantastic things” was that she didn’t have to go to any groups. (She went on to become an addiction professional, training for an advanced degree.)

The truth is that people often do know what will work best for them. As prominent addiction psychologist William Miller, PhD, said, “Those who choose from among options tend to ‘own’ what they’ve chosen and stay with it. So why would you not let clients choose? If one thing isn’t working, you can try something else.” Indeed, a 2009 review of psychological studies published in the Journal of Clinical Psychology indicated that clients matched to their preferred treatment were about half as likely to drop out of treatment and had close to a 60 percent chance of showing greater improvement when compared with clients not given a choice. There’s no question that our addiction treatment system would help more people if it moved away from one-size-fits-all approaches, recognizing that there are many different paths to recovery.

What choices do you think people should be offered in order to make addiction treatment more effective?

Follow me on Twitter @annemfletcher for daily updates on addiction, weight control, psychology, and health

Copyright Anne M. Fletcher

About the Author
Anne M. Fletcher, M.S., R.D.

Anne M. Fletcher, M.S., R.D., is the author of Inside Rehab: The Surprising Truth about Addiction Treatment – And How to Get Help That Works.

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