The evidence is not only clear that home and community based services have better outcomes in primary treatment, but that in-patient services actively harm you the longer you are in them. This can create secondary problems which themselves can be harder to treat than the original reason for admittance. Additionally learning skills to manage a long term illness in a hospital can be difficult to transfer to one’s actual lived life, leading to relapse. This cycle in itself creates further problems of treatment resistance.
Despite this, the addiction treatment industry is almost wholly focussed on getting you into in-patient ‘rehab’. Many providers will point to their full services as evidence they are meeting need, when in fact their services are full because of a range of open and not so open marketing and referral practices. This includes some that are downright illegal in many places, such as referral fees.
But even without referral fees the addiction industry is effectively a pyramid selling scam. It is bloated and interdependent.
A good example of this scam is what is known as ‘interventions’ and interventionists. This is a (self) recognised profession that wholly focuses on overcoming an addicts resistance to treatment, which as an idea is bizarre. The theory at work here is that the interventionist has special insight into the ‘denial’ of the addict and their loved ones. And therefore can help smash this denial and get the addict to rush off to a dangerous inpatient facility that the interventionist recommends.
Lack of insight into being ill is a common feature of most if not all mental health conditions – addiction isn’t special in that regard – but it seems it needs a special word (‘denial’) for what is commonplace. The term used is a very outmoded concept from Freud that suggests something is actively being done by the addict which needs to be broken. In mental and emotional health we still think about denial but mostly in the context of how it can protect people from harsh reality and therefore have helpful features. As a clinician I wouldn’t dream of smashing any part of a client’s psyche and especially not something that might be helping them. What we know is that as we give people better ways to cope, the ones that are double-edged, such as denial, fade out of use.
Imagine an interventionist being interviewed by a family who ask ‘how many people have you gotten into rehab?’ who says ‘actually, none’. Are they going to get the job? Unlikely.
There is a clear financial incentive, even without referral fees to get the addict into rehab. As you can imagine the rehabs themselves love and fete interventionists. The successful ones will make millions from this. And piously intone they are helping save lives, when in fact there’s little evidence that is true and quite a lot of evidence to the contrary. Interventionists are channelling patients into inappropriate inpatient facilities that provide treatment models (institution based) that are way out of date, ineffective and actually harmful.
Let’s imagine someone with depression, or anxiety or maybe bi-polar disorder. Would anyone think it’s acceptable to gather all the people that are important to them in one room to pile pressure on them to admit themselves to hospital. The pressure often takes the form of ‘if you don’t do this we will cut you off.’ In fact there are legal safeguards in place against this happening and only very proscribed circumstance under which pressure can be brought to bear on someone to accept treatment they don’t want.
None of the unhelpful and dubious assumptions underlying interventions are ever questioned and there is a symbiosis of rehab and the interventionist. They both need each other to exist. Of course referral fees do exist even here and they are in the form of ‘consultancy’ fees.
Rehabs turn failure to deliver effective treatment into a marketing gimmick, telling patients they will need multiple admissions to get well. And usually blame the addict for the failure to work their programme well enough. It’s an absolute truism in this work that addicts only begin the process of recovery after discharge. This is true in all mental health conditions. You don’t get well in hospital, you stabilise enough to go home and get well there.
In good rehabs, which do exist, from the moment of admission discharge is being planned for. But even the best rehab I’ve ever visited is still far behind the worst psychiatric ward I’ve visited in terms of admission and discharge. Rehabs routinely trot out the line that treatment will take 28 days, or six weeks, or longer. Even the worst (NHS) psychiatric ward in the UK will automatically be working to reduce the stay of any patient to an absolute minimum. It is absolutely standard practice in all rehabs to try to achieve opposite outcome, to keep patients in as long as possible.
This complete reversal of best practice in the rehab industry has led to even greater bloating of the market with the development of what are known as sober homes and sober services. It’s common for rehabs to talk in pseudo-clinical terms about primary, secondary and tertiary treatment. In mainstream mental health in the UK these terms refer to referral routes. Primary care is self-referral services such as an accident and emergency or GP services etc. Secondary and tertiary being services that are accessed by professional referral. This is fairly standard practice in most healthcare systems in Europe and the world.
The key point is that you will access these other services after discharge and they will be part of a package to avoid further inpatient stay, reducing institutionalisation and treatment resistance.
In the addiction industry secondary and tertiary refer to elongating the in-patient period to ‘sober homes’ which are theorised, without any evidence, to transition an addict back to their life. It’s interesting to note this transition always takes many months and often takes over a year. And it also costs a lot of money. They have sprung up largely because the relapse rate from ‘primary’ treatment is so bad. But of course this didn’t lead to a re-evaluation of the treatment model, it led to a continuation of the model into months and sometimes years of disabling support in mini institutions in the community.
If the addict wasn’t removed for their home and community at the primary stage and kept inside an institution for an abnormally long period of time, it can be seen that the transition issues might not exist. It’s a classic example of an industry providing a solution to a problem it has created.
To be truly healthy a provider of mental health services must be working towards not being relevant to a client or patient. To empower and enable the patients to manage their conditions for themselves. It’s sadly the case that there is on the whole a lack of this approach in addiction services. There is mostly an approach based on keeping the patient bound to them for as long as possible.
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