Why Addiction Treatment Is a Disaster

By Maia Szalavitz 07/06/12

If addiction is a medical disease, why have we abandoned it to untrained counselors, unproven treatments and unaccountable programs?

Addiction treatment is a "non-system." Photo via

Anyone who has been through rehab or any other type of addiction treatment in America knows that it is radically different from any other sort of medical care. Now, a groundbreaking new report from the National Center on Addiction and Substance Abuse at Columbia University confirms the woeful details. Titled “Addiction Medicine: Closing the Gap Between Science and Practice,” the study is scathing in its condemnation: addiction treatment is a “non-system” that the medical profession has almost entirely neglected, leaving it to a patchwork of treatment programs, including many that offer unproven therapies, untrained staff, little medical supervision and less accountability.

“Some [programs] promise ‘one time’ fixes; others offer posh residential treatment at astronomical prices with little evidence justifying the cost,” the report concludes. “Even for those who do have insurance coverage or can pay out of pocket, there are no outcome data reflecting the quality of treatment providers so that patients can make informed decisions.”

Advocates have long argued that addiction is a disease (a brain disease, according to neuroscientists), but we sure don’t treat it like one. Unlike with virtually any other medical condition, there is no accepted national standard of care. Some 90% of programs involve the use of 12-step programs—endorsing meeting, confession, humility and prayer as key parts of recovery—and these types of recommendations are, shall we say, rare in other mainstream medicine.

In fact, the main qualification for providing care is having suffered from addiction oneself. While there are many wonderful people in recovery who do great work helping others, there are also plenty who are complete disasters.

In some states, there are no requirements, so virtually anyone can set out a shingle and offer addiction treatment.

Lack of education almost certainly plays a critical role in the problem. The CASA report found that in 14 states there are no requirements that all addiction counselors must meet, which means that in many of them, anyone can set out a shingle and offer addiction treatment.

One result, as I noted in a previous column, is that dangerous folks can prey on desperate parents and patients: no one would argue that providing “intimacy therapy” for teenage girls by having sex with them is an evidence-based treatment strategy, but it’s very difficult to stop sexual predators from doing so if there are no educational or background checks required and no uniform licensing standards for counseling.

But even states that do license providers often don’t do much better. In many places, you can be trained by equally ignorant former addicts while working in, or even simply attending, a treatment center—and this experience constitutes, to a large degree, your qualifications for treating others. Only six states require counselors to have a bachelor’s degree, and just one requires a master’s.

This is especially disturbing in light of the fact that research doesn’t actually find an advantage in therapy providers’ “having been there” themselves. While there probably is one for some people, this attribute likely gets drowned out in the data by the fact that many addiction counselors present their own preferred version of recovery as the only way.

Nonetheless, as with other types of successful therapy, an essential quality is being empathetic and able to develop rapport with clients: while having personal experience can support empathy, if the counselor believes that a confrontational style is necessary, the connection may not help.

CASA’s report also found that nearly half of all people treated for illegal drug problems are court-mandated into treatment, which is troubling for two reasons. The first is that this offers providers a regular stream of clients who have no alternatives—no matter how bad a rehab’s care may be, the customer is always wrong. Indeed, it is the clients who are sent to prison if they fail; there are no consequences for the provider.

The second problem is a more subtle one: a reliance on the justice system for referrals provides little incentive for treatment to become less punitive and more supportive in order to attract voluntary patients. Programs filled with unwilling participants are also less helpful to those who really want to get clean—and because empathetic treatment is linked to better outcomes, the whole system is undermined.

The trust necessary for good treatment is hard to achieve because if your counselor is also in charge of sending you back to prison for not following rules, honesty isn’t exactly the best policy for self-preservation.

The CASA report makes a number of useful recommendations for change. It suggests expanding access to medications used for treatment, like methadone, buprenorphine (Suboxone, Subutex), naltrexone (reVia, Vivitrol) and others. It calls for requiring physicians to be educated in medical school about addictions—something that is now rare.

It also demands that all treatment providers be licensed as healthcare organizations, with national standards for accreditation. These measures would not only improve quality but also potentially reduce abuse in programs that currently often avoid regulation by labeling themselves as “religious centers,” “boot camps,” “emotional growth schools” and “wilderness programs.” We don’t allow faith-based groups to advertise as treatment for cancer or heart disease without being licensed as healthcare providers and following the standard of care: why should addiction be any different?

American rehab erred when it allowed the majority of treatment program time to be taken up by the 12 steps.

It’s true that these standards may make it difficult for some people in recovery to be qualified as counselors. But frankly, I think it should be harder. AA’s own 12 traditions stress that no one should be paid to do 12th-step work, but far too much treatment involves teaching about the steps and about the idea that the “only alternative is jails, institutions or death.” In my view that’s malpractice: it denies people who could be helped by other options the hope that there are such options.

American rehab erred when it allowed the majority of treatment program time to be taken up by the steps and related ideology. You can get that for free in the rooms. While treatment should refer people for support via 12-step programs (data does show that those who do like them do better in them), it shouldn’t require this, nor should providers charge money for what is essentially sponsorship and self-help.

The new CASA report offers a step in the right direction, but if we don’t address the issues related to the fact that so much of our system is still too reliant on charging people for 12-step-related advice, we won’t ever be able to adopt more evidence-based care and provide well-paid career options for those in recovery who do get educated about the multiple ways to treat addiction.

Maia Szalavitz is a columnist at The Fix. She is also a health reporter at Time magazine online, and co-author, with Bruce Perry, of Born for Love: Why Empathy Is Essential—and Endangered (Morrow, 2010), and author of Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids (Riverhead, 2006). 

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Maia Szalavitz is an author and journalist working at the intersection of brain, culture and behavior.  She has reported for Time magazine online, and is the co-author, with Bruce Perry, of Born for Love: Why Empathy Is Essential—and Endangered, and author of Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids. You can find her on Linkedin and  Twitter.