Interviews with the Experts: Anne M. Fletcher, Author of Inside Rehab and Melissa Delise Ruby of Time For Ethics In Addiction Treatment

Experts on the Rehab Industry Speak Out

As part of our ongoing series of interviews with experts, I interviewed Anne M. Fletcher, author of the book Inside Rehab: The Surprising Truth About Addiction Treatment and How to Get Help That Works 

How did you get interested in the topic of substance use disorder treatment? 

I’m a Registered Dietitian by training, but I didn’t work in the field for very long before I decided I wanted to be a writer.  I was very interested in how people change, not just now they change initially but how they maintain that change.  I wrote a series of books about people who lost weight and kept it off, then extended that work to teenagers who lost weight in a healthy manner. I convinced my editor that I could use the same model with people who overcame a drinking problem and wrote Sober for Good.  

I was interested in the subject because of my own struggles with alcohol. I never thought I’d write another book about substance use problems, but then I had a dream that I was in a women’s rehab.  It was around the time Lindsay Lohan and Brittany Spears were having all their troubles, going in and out of rehabs. I dreamt that I was in a rehab (I had never actually gone to one) and that I was going around interviewing women about their lives and their problems. I woke up and I called my agent and I said, “There really is a book here, it’s about going inside rehab,” and closely examining the industry.

I was very interested in the traditional 12-Step-based Minnesota Model type programs.  I was invited to visit fifteen rehabs and outpatient programs, from celebrity rehabs to programs that treat indigent people. I told the rehabs, “I’m going to find people who loved your program and people who hated it and I’m going to tell the story.”  They were willing to have me sit in with women’s programs and their adolescent programs, sometimes for a week at a time. 

What did you find out when you went inside rehab? 

The treatment was incredibly one size fits all, even at the rehabs where people were paying over $30,000 for a 28 to 30 day stay. So many people were getting the same treatment. One woman said to me, “I went back to my shared room and I looked around and we were all doing the same homework at night.”  Treatment was not individualized, it was largely group-based. The amount of group based counseling as opposed to individual counseling was shocking. At the high end rehabs there was some type of group counseling for about 8 hours a day, not including meals. The individual counseling at a high end residential rehab could work out to five hours a week or less. Another part of the one size fits all treatment was the ubiquity of Alcoholics Anonymous.

If you could list your major findings inside rehab, what would they be? 

– There is a huge gap between science and practice. Most addiction programs say they are using scientifically backed approaches, but they are not using them as they were designed to be used in research studies.

– Most programs had clients do timelines of their addiction. There is no evidence that is helpful.

– Programs relied heavily on educational lectures and films. Studies show these to be among the least effective ways to treat alcohol problems.

– I found a consistent failure to send patients home on medications like suboxone, even if they were used in treatment.

– The things we think should protect us don’t. Credentialing and licensing don’t mean what people think they do.  Just because something has JCAHO certification doesn’t mean you’re getting evidence-based treatment, and it doesn’t mean the people taking care of you have the kinds of degrees that you think they should.  Most of the counselors have a bachelor's degree or less. They are attempting to treat what is among the most complicated of disorders, and as many as 50% of clients have co-occurring psychological disorders, yet they are using the least qualified people to treat it. With any other mental health disorder, you would be treated by someone with at least a master’s degree. There are very few people with master’s degrees providing the bulk of the care in traditional 12 Step rehabs. 

What was your experience when your own daughter went to rehab? 

At one rehab she was put into a group with adult health care professionals when she was only 21. The staff took away the treatment objectives she had written for herself and gave her their treatment objectives. Even though they knew that she had been sexually assaulted, another rehab put her into a co-ed living situation. She was sexually harassed by a young man there.  She used again as soon as she got back from the two rehabs we sent her to.  

She has now found her own way. She found her own psychiatrist, her own therapist, and her own internist. She is managing her own care, and she is doing well. 

What would you say about sending an adolescent to rehab? 

Don’t send an adolescent to rehab or an outpatient program as your first resort.  Try to find an individual therapist. I live in a town of 70 - 80,000 people, and there are at least several people who are qualified to treat adolescents with substance use issues here. Do not rely on a primary care doctor - this is not their area of expertise, and they are likely to say, “Go to rehab.”   Go to a mental health professional who is qualified to treat substance use problems. 

I really have issues about sending young people to 12 Step meetings. I just don’t think it’s safe.  In schools and almost any other setting, anyone who works with adolescents has to pass a background check, yet we are telling them to go to 12 Step meetings and get a sponsor?

I also think that the labeling, having to say, “I’m an alcoholic,” at a young age, is very damaging.  In fact, most of these young people will mature out of their substance use problem. My daughter was told she could never touch alcohol again, and she drinks without a problem. Having to wear that label is harmful to adolescents. We don’t even say “diabetic” anymore, we say “person with diabetes.”

What are your parting words for families of people struggling with substance use problems?

Bear in mind that most people overcome such problems without going to rehab. They do so completely on their own, by attending support groups (not just AA – there’s SMART Recovery, Women for Sobriety, Lifering, and more), and/or by seeing a counselor or therapist individually. And forget tough love. It invariably doesn’t work, while the harm reduction model does. That is, love the person unconditionally – of course setting boundaries along the way – doing your best to meet them where they are at.

I also asked Melissa Delise Ruby of Time for Ethics In Addiction Treatment to share her perspective on the rehab industry. Here’s Melissa:

I’m a mom whose child was unfortunately brokered by many unethical rehabs. When he went missing, I went searching for him. I quickly found that there wasn’t much help to find him. It was like people thought, “Who needs this missing person anyway?” It was left up to me and the rest of my family to find my son, and that was a very lonely feeling.

I soon realized that it was within my skill set to do research on these facilities. I’m just a mom with a knack for research. My goal is to educate families on how to look for the warning signs in rehab facilities, so that they do not fall into this cycle of brokering. I went looking for confirmation of what I was seeing because at first I thought, “This can’t possibly be true.” But it is.

While there are good rehabs, unfortunately there are those that prey on families’ weakness and vulnerability at a time of crisis. At that moment when we think our baby is going to die, or our child comes to us and says they are ready to get help, we want to help them NOW! Families go online and random people pop up saying, “Call this place, call that place.”

I try to tell families, “I know you want to get help for your loved one now, but don’t take advice from random people on the internet. Take the time to do your own research. If your child is ready now, even if suddenly they’re not, they will call you back again. This research doesn’t take weeks or months. It might only take twenty-four hours. By the time they call you back, you will have made a list you are comfortable with. It’s better to take the time now to find a safe facility than to send your child to a place that will do further harm.”

I tell families to slow down and take a deep breath. I know that’s hard, but when we show that we aren’t acting on impulse, we are modeling for our children how to resist impulsivity. That’s the behavior we want our loved ones to model, not acting in a panic.

The consequences of acting in panic mode could be that your loved one ends up in a place where the staff are not credentialed, there is a cookie cutter protocol, and your child’s medical detox is being managed by a doctor who isn’t even on site, hasn’t even seen your child, and is just telling unqualified staff what to do by phone. There’s a laundry list of bad things that could happen, but all result in more harm to your loved one.

I learned from a personal experience I regret that we have to listen to our children when they tell us they are being harmed. When my son first left a rehab, he told me he was being harmed and drugged, and I didn’t believe him. I thought, “You just ran into the streets because you wanted to return to drug use again.” The rehab told me that he was just being manipulative, but in fact the rehab was manipulating me. I think that when rehabs use language like “manipulative” and other stigmatizing language, that’s a red flag. By listening to the rehab, I put my son in a position where he felt, “Even my mom isn’t listening to me.”

You know your child better than anyone. If your child doesn’t sound like themselves to you, it’s a warning sign. In many of these facilities, they won’t let patients talk to family or friends without a staff member present. Some of them even threaten retaliation if the patient says anything negative. While it may sound scary, arrange a kind of “safe word” in advance of admitting your loved one to a rehab. Tell your child to say something specific, something they would not usually say, if the rehab is harming them. You may be afraid that this will scare your loved one out of going to treatment, but it is more likely to show that you care most about their safety, and that you trust them. It’s just like how we teach our children about “stranger danger” when they are little.

Not every family has this bond, but often the bond between a momma and a baby is extremely strong. If your child sounds like they are being drugged, or even if you have the intuition that something is off, go with that feeling. It is better to be safe than to risk that your child will be hurt.

Here is a list of red flags that a rehab is NOT safe:

- A facility or person offering to pay for the flight to treatment.

- A facility or person asking you to sign a promissory note for a flight to treatment.

- A facility or person offering you payment or gifts to attend treatment.

- A facility or person offering you free or reduced rent at a sober living if you attend a specific IOP or PHP program.

- A marketing person asking for your Social Security number.

- Be wary of individuals on social media offering you help. Especially if there’s no transparency about what center(s) they work with.

- Facility websites that don’t show all staff members and their credentials.

- Facility websites whose numbers route to a call center.

- Facility websites that don’t offer transparency about their location.

- A Facility that offers services (for example, detox), but they aren’t actually licensed to provide those services.

Look up the state standards for credentials of staff, and make sure the facility has properly credentialed staff. Make sure the facility is licensed to provide the services they claim to render. These facilities will tell you how luxurious they are, but I tell families, “If it sounds too good to be true, it is.”

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